| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
994 |
992 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,498 |
1,498 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
2,114 |
2,082 |
$27K |
| D0274 |
Bitewings - four radiographic images |
922 |
921 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
232 |
137 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,390 |
1,389 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,800 |
1,758 |
$18K |
| D1120 |
Prophylaxis - child |
373 |
373 |
$13K |
| D0330 |
Panoramic radiographic image |
147 |
147 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
121 |
112 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
89 |
$4K |
| D0272 |
Bitewings - two radiographic images |
164 |
164 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$970.00 |