| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
482 |
466 |
$19K |
| D1120 |
Prophylaxis - child |
588 |
581 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
787 |
773 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
789 |
780 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
296 |
265 |
$8K |
| D0274 |
Bitewings - four radiographic images |
303 |
296 |
$8K |
| D0272 |
Bitewings - two radiographic images |
393 |
389 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
89 |
67 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
206 |
201 |
$6K |
| D0330 |
Panoramic radiographic image |
139 |
131 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
48 |
26 |
$3K |
| D1206 |
Topical application of fluoride varnish |
116 |
106 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
59 |
$715.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
13 |
$156.00 |