| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
285 |
285 |
$21K |
| D1120 |
Prophylaxis - child |
523 |
523 |
$16K |
| D1206 |
Topical application of fluoride varnish |
531 |
531 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
299 |
299 |
$5K |
| D1330 |
|
654 |
654 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
572 |
563 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
12 |
$3K |
| D1351 |
Sealant - per tooth |
355 |
95 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
815 |
502 |
$2K |
| D1110 |
Prophylaxis - adult |
39 |
39 |
$2K |
| D0272 |
Bitewings - two radiographic images |
218 |
218 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
26 |
26 |
$960.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
29 |
$919.60 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$165.00 |