| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
228 |
228 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
96 |
71 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
308 |
308 |
$7K |
| D1120 |
Prophylaxis - child |
153 |
153 |
$5K |
| D0274 |
Bitewings - four radiographic images |
138 |
138 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
34 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
166 |
166 |
$3K |
| D1206 |
Topical application of fluoride varnish |
124 |
124 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
60 |
57 |
$2K |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$1K |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
83 |
$949.36 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
20 |
$799.80 |