| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
957 |
957 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,179 |
1,179 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
259 |
186 |
$26K |
| D0274 |
Bitewings - four radiographic images |
952 |
952 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,476 |
1,476 |
$24K |
| D1120 |
Prophylaxis - child |
508 |
508 |
$18K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
327 |
288 |
$11K |
| D0272 |
Bitewings - two radiographic images |
462 |
462 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
109 |
89 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
127 |
127 |
$5K |
| D0330 |
Panoramic radiographic image |
90 |
90 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
24 |
$320.75 |