| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
196 |
$3K |
| D1206 |
Topical application of fluoride varnish |
207 |
204 |
$3K |
| D1120 |
Prophylaxis - child |
168 |
165 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
115 |
85 |
$2K |
| D1351 |
Sealant - per tooth |
196 |
47 |
$2K |
| D9920 |
|
58 |
49 |
$1K |
| D0272 |
Bitewings - two radiographic images |
138 |
136 |
$1K |
| D1330 |
|
213 |
209 |
$998.70 |
| D0330 |
Panoramic radiographic image |
49 |
48 |
$892.64 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
15 |
$875.40 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$854.52 |
| D0220 |
Intraoral - periapical first radiographic image |
237 |
214 |
$745.26 |
| D0230 |
Intraoral - periapical each additional radiographic image |
253 |
210 |
$648.48 |
| D1110 |
Prophylaxis - adult |
29 |
29 |
$400.44 |
| D1354 |
|
61 |
14 |
$302.95 |
| D0274 |
Bitewings - four radiographic images |
31 |
30 |
$245.46 |
| D0603 |
|
33 |
31 |
$13.00 |