| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,022 |
1,020 |
$60K |
| D1206 |
Topical application of fluoride varnish |
1,221 |
1,214 |
$22K |
| D0330 |
Panoramic radiographic image |
289 |
288 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
640 |
637 |
$21K |
| D0272 |
Bitewings - two radiographic images |
916 |
912 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
298 |
171 |
$20K |
| D0120 |
Periodic oral evaluation - established patient |
628 |
627 |
$17K |
| D1110 |
Prophylaxis - adult |
175 |
173 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
87 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
228 |
221 |
$7K |
| D1351 |
Sealant - per tooth |
173 |
55 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
40 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
136 |
134 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
14 |
$185.25 |