| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
711 |
709 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
212 |
161 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,064 |
1,061 |
$21K |
| D1206 |
Topical application of fluoride varnish |
1,126 |
1,122 |
$19K |
| D0274 |
Bitewings - four radiographic images |
386 |
385 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
255 |
251 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
421 |
416 |
$6K |
| D1120 |
Prophylaxis - child |
214 |
214 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
503 |
242 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$753.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$201.30 |