| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,488 |
1,455 |
$61K |
| D0120 |
Periodic oral evaluation - established patient |
2,353 |
2,291 |
$54K |
| D1120 |
Prophylaxis - child |
1,282 |
1,246 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,797 |
1,759 |
$37K |
| D0272 |
Bitewings - two radiographic images |
458 |
448 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
44 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
13 |
$996.21 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
39 |
38 |
$861.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$339.36 |