| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
526 |
519 |
$21K |
| D1206 |
Topical application of fluoride varnish |
379 |
374 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
316 |
303 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
155 |
127 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
13 |
$1K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$707.40 |
| D0220 |
Intraoral - periapical first radiographic image |
73 |
71 |
$474.91 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$366.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
42 |
42 |
$179.20 |
| D0274 |
Bitewings - four radiographic images |
16 |
13 |
$118.30 |