| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,273 |
2,254 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,549 |
3,515 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
3,606 |
3,580 |
$63K |
| D1120 |
Prophylaxis - child |
2,059 |
2,033 |
$60K |
| D0274 |
Bitewings - four radiographic images |
1,599 |
1,590 |
$37K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
987 |
953 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
738 |
726 |
$19K |
| D0272 |
Bitewings - two radiographic images |
699 |
691 |
$13K |
| D1206 |
Topical application of fluoride varnish |
764 |
759 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
37 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
44 |
44 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
241 |
237 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
71 |
53 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$842.28 |