| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
259 |
252 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
177 |
162 |
$6K |
| D0274 |
Bitewings - four radiographic images |
173 |
172 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
204 |
203 |
$4K |
| D1206 |
Topical application of fluoride varnish |
194 |
193 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
26 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
26 |
$814.06 |
| D0220 |
Intraoral - periapical first radiographic image |
78 |
57 |
$614.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
68 |
49 |
$547.82 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$501.49 |
| D1208 |
Topical application of fluoride, excluding varnish |
20 |
20 |
$415.80 |