| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,206 |
1,110 |
$57K |
| D0274 |
Bitewings - four radiographic images |
1,257 |
1,148 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,668 |
1,524 |
$36K |
| D1120 |
Prophylaxis - child |
758 |
690 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,390 |
1,276 |
$21K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
91 |
40 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
208 |
182 |
$6K |
| D0272 |
Bitewings - two radiographic images |
322 |
280 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
239 |
217 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
48 |
41 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$624.47 |