| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
620 |
617 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,101 |
1,094 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
796 |
786 |
$19K |
| D1120 |
Prophylaxis - child |
585 |
581 |
$17K |
| D0272 |
Bitewings - two radiographic images |
763 |
759 |
$14K |
| D0330 |
Panoramic radiographic image |
305 |
301 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
327 |
317 |
$9K |
| D0274 |
Bitewings - four radiographic images |
293 |
291 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
118 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
25 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$1K |
| D2140 |
|
13 |
12 |
$761.28 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$317.20 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$278.92 |