| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
670 |
243 |
$75K |
| D1110 |
Prophylaxis - adult |
779 |
779 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,225 |
1,225 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,417 |
1,417 |
$24K |
| D1120 |
Prophylaxis - child |
626 |
626 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
478 |
450 |
$16K |
| D0274 |
Bitewings - four radiographic images |
524 |
524 |
$15K |
| D0330 |
Panoramic radiographic image |
239 |
239 |
$13K |
| D0272 |
Bitewings - two radiographic images |
649 |
649 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
183 |
183 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
137 |
137 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
45 |
$598.50 |