| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
684 |
626 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
670 |
617 |
$14K |
| D1206 |
Topical application of fluoride varnish |
707 |
656 |
$12K |
| D0274 |
Bitewings - four radiographic images |
422 |
385 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
87 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
118 |
116 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
388 |
348 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
107 |
97 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
166 |
136 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
26 |
$756.93 |
| D0330 |
Panoramic radiographic image |
14 |
12 |
$269.60 |