| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
151 |
150 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
29 |
$4K |
| D1120 |
Prophylaxis - child |
103 |
102 |
$3K |
| D1206 |
Topical application of fluoride varnish |
130 |
130 |
$3K |
| D1351 |
Sealant - per tooth |
94 |
28 |
$3K |
| D0330 |
Panoramic radiographic image |
59 |
59 |
$2K |
| D0272 |
Bitewings - two radiographic images |
61 |
61 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
16 |
$481.72 |
| D1110 |
Prophylaxis - adult |
17 |
17 |
$457.18 |
| D0274 |
Bitewings - four radiographic images |
17 |
17 |
$413.33 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
36 |
$345.87 |