| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
53 |
53 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
66 |
14 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
193 |
168 |
$5K |
| D1120 |
Prophylaxis - child |
160 |
144 |
$5K |
| D1351 |
Sealant - per tooth |
161 |
25 |
$3K |
| D1206 |
Topical application of fluoride varnish |
204 |
186 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
174 |
162 |
$2K |
| D0272 |
Bitewings - two radiographic images |
99 |
88 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
175 |
101 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
54 |
52 |
$1K |
| D0330 |
Panoramic radiographic image |
52 |
43 |
$836.20 |
| D1110 |
Prophylaxis - adult |
16 |
14 |
$720.32 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
22 |
17 |
$515.09 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$205.80 |
| D1330 |
|
173 |
165 |
$84.53 |
| D0603 |
|
271 |
256 |
$0.00 |
| D1310 |
|
103 |
102 |
$0.00 |
| D0602 |
|
51 |
48 |
$0.00 |