| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
220 |
181 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
292 |
249 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
317 |
216 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
30 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
448 |
349 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
139 |
129 |
$2K |
| D0274 |
Bitewings - four radiographic images |
215 |
172 |
$2K |
| D1206 |
Topical application of fluoride varnish |
123 |
114 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
38 |
$1K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
38 |
31 |
$712.38 |
| D0230 |
Intraoral - periapical each additional radiographic image |
507 |
204 |
$663.96 |
| D0330 |
Panoramic radiographic image |
22 |
17 |
$507.15 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
25 |
22 |
$480.00 |