| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
575 |
575 |
$21K |
| D1206 |
Topical application of fluoride varnish |
704 |
704 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
236 |
236 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
92 |
38 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
30 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
238 |
238 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
163 |
151 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
120 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
374 |
132 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
260 |
258 |
$4K |
| D0272 |
Bitewings - two radiographic images |
119 |
119 |
$2K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$2K |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$928.00 |