| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
906 |
891 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,358 |
1,344 |
$36K |
| D1120 |
Prophylaxis - child |
662 |
651 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
777 |
771 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
307 |
301 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
198 |
189 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
495 |
481 |
$7K |
| D0272 |
Bitewings - two radiographic images |
299 |
297 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
25 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
164 |
161 |
$2K |
| D1351 |
Sealant - per tooth |
35 |
13 |
$992.85 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
21 |
13 |
$587.68 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$315.77 |