| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
28 |
12 |
$13K |
| D1110 |
Prophylaxis - adult |
158 |
151 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
83 |
80 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
123 |
109 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
271 |
233 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
27 |
$2K |
| D9310 |
|
15 |
13 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
32 |
24 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$320.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
20 |
13 |
$225.27 |