| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
406 |
402 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
100 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
387 |
386 |
$8K |
| D1206 |
Topical application of fluoride varnish |
510 |
508 |
$7K |
| D0330 |
Panoramic radiographic image |
152 |
150 |
$5K |
| D1110 |
Prophylaxis - adult |
110 |
110 |
$5K |
| D0274 |
Bitewings - four radiographic images |
195 |
194 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
96 |
93 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
154 |
151 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
95 |
68 |
$681.13 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$660.92 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
15 |
$585.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$303.60 |