| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,250 |
1,120 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,583 |
1,440 |
$29K |
| D0274 |
Bitewings - four radiographic images |
920 |
833 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
317 |
150 |
$18K |
| D1120 |
Prophylaxis - child |
605 |
541 |
$16K |
| D1206 |
Topical application of fluoride varnish |
633 |
574 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
875 |
792 |
$11K |
| D0330 |
Panoramic radiographic image |
316 |
257 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
73 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
216 |
179 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
304 |
288 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
135 |
116 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
255 |
226 |
$3K |
| D0272 |
Bitewings - two radiographic images |
152 |
131 |
$2K |