| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
426 |
423 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
475 |
472 |
$13K |
| D1206 |
Topical application of fluoride varnish |
390 |
387 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
167 |
158 |
$5K |
| D0272 |
Bitewings - two radiographic images |
210 |
209 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
348 |
343 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
455 |
323 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
181 |
181 |
$3K |
| D1110 |
Prophylaxis - adult |
46 |
46 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
27 |
$2K |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
13 |
12 |
$929.50 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$585.00 |