| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
302 |
302 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
358 |
357 |
$7K |
| D1120 |
Prophylaxis - child |
206 |
206 |
$5K |
| D1110 |
Prophylaxis - adult |
139 |
138 |
$4K |
| D1330 |
|
387 |
386 |
$4K |
| D1351 |
Sealant - per tooth |
142 |
44 |
$3K |
| D0274 |
Bitewings - four radiographic images |
126 |
125 |
$2K |
| D0272 |
Bitewings - two radiographic images |
134 |
134 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
302 |
301 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
41 |
38 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
295 |
293 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
36 |
$1K |
| D0330 |
Panoramic radiographic image |
19 |
19 |
$1K |
| D1206 |
Topical application of fluoride varnish |
23 |
23 |
$453.33 |