| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
150 |
143 |
$4K |
| D1120 |
Prophylaxis - child |
153 |
143 |
$4K |
| D1351 |
Sealant - per tooth |
321 |
43 |
$3K |
| D1110 |
Prophylaxis - adult |
89 |
76 |
$3K |
| D1206 |
Topical application of fluoride varnish |
121 |
109 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
80 |
72 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
134 |
122 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
51 |
50 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
52 |
34 |
$821.10 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$567.48 |
| D0230 |
Intraoral - periapical each additional radiographic image |
76 |
58 |
$369.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
45 |
42 |
$309.50 |
| D0274 |
Bitewings - four radiographic images |
19 |
14 |
$277.84 |
| D0272 |
Bitewings - two radiographic images |
25 |
24 |
$272.37 |
| D0330 |
Panoramic radiographic image |
14 |
12 |
$148.40 |