| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
699 |
681 |
$17K |
| D1110 |
Prophylaxis - adult |
350 |
344 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
484 |
479 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
184 |
182 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
245 |
243 |
$6K |
| D0274 |
Bitewings - four radiographic images |
402 |
395 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
173 |
168 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
648 |
609 |
$3K |
| D0330 |
Panoramic radiographic image |
236 |
229 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
25 |
15 |
$2K |
| D1120 |
Prophylaxis - child |
58 |
58 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
35 |
33 |
$950.72 |
| D0230 |
Intraoral - periapical each additional radiographic image |
273 |
161 |
$661.74 |