| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
810 |
801 |
$37K |
| D1120 |
Prophylaxis - child |
682 |
680 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
96 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
250 |
231 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
55 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
477 |
475 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
583 |
583 |
$1K |
| D0274 |
Bitewings - four radiographic images |
120 |
120 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
30 |
29 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
320 |
319 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
50 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$0.00 |