| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
1,055 |
1,024 |
$22K |
| D1120 |
Prophylaxis - child |
751 |
727 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
226 |
159 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
169 |
114 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
437 |
410 |
$10K |
| D0330 |
Panoramic radiographic image |
294 |
280 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
496 |
451 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
384 |
378 |
$7K |
| D0272 |
Bitewings - two radiographic images |
165 |
163 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
55 |
54 |
$712.80 |
| D1110 |
Prophylaxis - adult |
14 |
13 |
$500.50 |
| D1208 |
Topical application of fluoride, excluding varnish |
20 |
17 |
$240.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$201.60 |