| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
568 |
134 |
$7K |
| D1110 |
Prophylaxis - adult |
197 |
197 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
318 |
318 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
30 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
285 |
268 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
154 |
148 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
49 |
47 |
$2K |
| D1120 |
Prophylaxis - child |
40 |
40 |
$915.18 |
| D0210 |
Intraoral - complete series of radiographic images |
107 |
76 |
$859.29 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$529.10 |