| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
715 |
713 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,323 |
1,320 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,464 |
1,463 |
$22K |
| D1120 |
Prophylaxis - child |
648 |
647 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
177 |
120 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
335 |
322 |
$8K |
| D0272 |
Bitewings - two radiographic images |
252 |
250 |
$5K |
| D0330 |
Panoramic radiographic image |
104 |
104 |
$4K |
| D1351 |
Sealant - per tooth |
140 |
44 |
$3K |
| D0274 |
Bitewings - four radiographic images |
113 |
113 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
207 |
207 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
364 |
162 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
16 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$319.55 |