| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,157 |
1,140 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,161 |
1,150 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
828 |
823 |
$17K |
| D0272 |
Bitewings - two radiographic images |
878 |
867 |
$16K |
| D1206 |
Topical application of fluoride varnish |
736 |
725 |
$15K |
| D1120 |
Prophylaxis - child |
352 |
351 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
356 |
351 |
$10K |
| D0330 |
Panoramic radiographic image |
125 |
125 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
80 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
26 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
13 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
18 |
13 |
$526.50 |