| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
173 |
170 |
$7K |
| D1206 |
Topical application of fluoride varnish |
322 |
305 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
232 |
219 |
$5K |
| D2740 |
Crown - porcelain/ceramic |
12 |
12 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
57 |
56 |
$3K |
| D1120 |
Prophylaxis - child |
74 |
74 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
182 |
173 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
63 |
$2K |
| D0274 |
Bitewings - four radiographic images |
58 |
58 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
16 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
94 |
91 |
$860.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
29 |
27 |
$831.76 |