| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,817 |
2,817 |
$58K |
| D1120 |
Prophylaxis - child |
1,687 |
1,687 |
$49K |
| D1110 |
Prophylaxis - adult |
1,070 |
1,070 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,456 |
1,456 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,388 |
2,388 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
465 |
296 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
262 |
165 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
40 |
38 |
$988.37 |
| D0330 |
Panoramic radiographic image |
16 |
16 |
$780.48 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$366.00 |