| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0145 |
Oral evaluation for a patient under three years of age |
177 |
177 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
181 |
37 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
70 |
68 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
73 |
71 |
$2K |
| D1120 |
Prophylaxis - child |
48 |
48 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
105 |
104 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
75 |
$942.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$713.44 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
22 |
22 |
$596.42 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$449.93 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$423.84 |
| D0603 |
|
323 |
322 |
$0.00 |