| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
416 |
407 |
$11K |
| D1120 |
Prophylaxis - child |
213 |
204 |
$8K |
| D1206 |
Topical application of fluoride varnish |
387 |
373 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
105 |
96 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
26 |
$6K |
| D0274 |
Bitewings - four radiographic images |
139 |
136 |
$4K |
| D1110 |
Prophylaxis - adult |
79 |
79 |
$4K |
| D0330 |
Panoramic radiographic image |
59 |
58 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$1K |
| D0272 |
Bitewings - two radiographic images |
34 |
34 |
$792.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$517.00 |