| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,556 |
2,556 |
$125K |
| D0120 |
Periodic oral evaluation - established patient |
3,144 |
3,144 |
$72K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
681 |
452 |
$65K |
| D0274 |
Bitewings - four radiographic images |
1,399 |
1,399 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,153 |
2,153 |
$35K |
| D1120 |
Prophylaxis - child |
840 |
840 |
$29K |
| D0272 |
Bitewings - two radiographic images |
1,303 |
1,303 |
$25K |
| D0330 |
Panoramic radiographic image |
366 |
366 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
418 |
418 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
992 |
982 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
212 |
212 |
$8K |
| D1206 |
Topical application of fluoride varnish |
459 |
459 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
56 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
66 |
56 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
66 |
66 |
$683.01 |