| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
711 |
703 |
$20K |
| D1110 |
Prophylaxis - adult |
228 |
227 |
$12K |
| D0274 |
Bitewings - four radiographic images |
368 |
366 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
757 |
748 |
$11K |
| D1120 |
Prophylaxis - child |
259 |
254 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
12 |
$3K |
| D1351 |
Sealant - per tooth |
93 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
59 |
57 |
$1K |
| D0330 |
Panoramic radiographic image |
31 |
30 |
$750.03 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18 |
16 |
$433.76 |
| D0602 |
|
524 |
518 |
$0.00 |
| D0603 |
|
12 |
12 |
$0.00 |