| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
405 |
403 |
$12K |
| D1120 |
Prophylaxis - child |
338 |
337 |
$11K |
| D1206 |
Topical application of fluoride varnish |
383 |
381 |
$8K |
| D0330 |
Panoramic radiographic image |
118 |
118 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
407 |
128 |
$3K |
| D1110 |
Prophylaxis - adult |
74 |
72 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
17 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
65 |
61 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
156 |
152 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
17 |
$2K |
| D1351 |
Sealant - per tooth |
57 |
15 |
$1K |
| D0274 |
Bitewings - four radiographic images |
58 |
58 |
$1K |
| D0272 |
Bitewings - two radiographic images |
76 |
76 |
$1K |