| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
109 |
$3K |
| D1120 |
Prophylaxis - child |
97 |
97 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
19 |
$3K |
| D1206 |
Topical application of fluoride varnish |
109 |
109 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
14 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
47 |
35 |
$2K |
| D0272 |
Bitewings - two radiographic images |
47 |
47 |
$739.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
81 |
29 |
$418.50 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
48 |
$373.06 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$360.08 |