| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,640 |
1,619 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
1,725 |
1,713 |
$44K |
| D0274 |
Bitewings - four radiographic images |
1,227 |
1,210 |
$36K |
| D1120 |
Prophylaxis - child |
741 |
733 |
$25K |
| D1206 |
Topical application of fluoride varnish |
735 |
729 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
859 |
837 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
100 |
78 |
$13K |
| D0330 |
Panoramic radiographic image |
202 |
200 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
281 |
279 |
$11K |
| D0272 |
Bitewings - two radiographic images |
459 |
451 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
34 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
17 |
15 |
$912.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
13 |
$246.00 |
| D9987 |
|
138 |
132 |
$0.00 |
| D9986 |
|
12 |
12 |
$0.00 |