| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,759 |
1,756 |
$78K |
| D0120 |
Periodic oral evaluation - established patient |
1,765 |
1,763 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,756 |
1,754 |
$44K |
| D1120 |
Prophylaxis - child |
510 |
510 |
$21K |
| D0274 |
Bitewings - four radiographic images |
1,609 |
1,607 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
343 |
330 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
2,335 |
2,285 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
78 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
248 |
248 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,137 |
2,106 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
236 |
236 |
$6K |
| D0180 |
|
59 |
59 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
12 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
25 |
$695.00 |
| D1353 |
|
51 |
13 |
$510.00 |