| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
361 |
325 |
$13K |
| D1354 |
|
239 |
50 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
166 |
93 |
$11K |
| D1206 |
Topical application of fluoride varnish |
537 |
515 |
$10K |
| D0272 |
Bitewings - two radiographic images |
448 |
433 |
$8K |
| D1120 |
Prophylaxis - child |
209 |
196 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
45 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
288 |
274 |
$7K |
| D1110 |
Prophylaxis - adult |
88 |
86 |
$5K |
| D0330 |
Panoramic radiographic image |
74 |
69 |
$4K |
| D1351 |
Sealant - per tooth |
63 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
74 |
71 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
53 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
17 |
15 |
$616.00 |
| D0220 |
Intraoral - periapical first radiographic image |
52 |
45 |
$577.50 |
| D0350 |
|
67 |
65 |
$20.00 |
| D0431 |
|
59 |
58 |
$0.00 |