| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
404 |
404 |
$17K |
| D1120 |
Prophylaxis - child |
478 |
467 |
$14K |
| D0330 |
Panoramic radiographic image |
168 |
166 |
$9K |
| D0274 |
Bitewings - four radiographic images |
272 |
266 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
392 |
386 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
29 |
13 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
227 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
223 |
100 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
55 |
46 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
43 |
33 |
$904.53 |
| D1206 |
Topical application of fluoride varnish |
25 |
25 |
$644.97 |