| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
81 |
$1K |
| D1206 |
Topical application of fluoride varnish |
100 |
94 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
15 |
$906.05 |
| D1120 |
Prophylaxis - child |
69 |
64 |
$776.20 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
62 |
45 |
$743.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
161 |
80 |
$510.24 |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
83 |
$282.44 |
| D1330 |
|
66 |
60 |
$87.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$79.32 |