| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
195 |
193 |
$4K |
| D1120 |
Prophylaxis - child |
133 |
132 |
$4K |
| D1206 |
Topical application of fluoride varnish |
217 |
214 |
$4K |
| D1351 |
Sealant - per tooth |
147 |
36 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
37 |
$3K |
| D1110 |
Prophylaxis - adult |
70 |
68 |
$3K |
| D0274 |
Bitewings - four radiographic images |
70 |
68 |
$2K |
| D0272 |
Bitewings - two radiographic images |
96 |
95 |
$2K |
| D0330 |
Panoramic radiographic image |
20 |
19 |
$698.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
31 |
28 |
$620.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
15 |
$391.00 |