| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
885 |
885 |
$40K |
| D1120 |
Prophylaxis - child |
1,187 |
1,187 |
$36K |
| D0330 |
Panoramic radiographic image |
653 |
653 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,391 |
1,391 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,844 |
1,844 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
235 |
193 |
$24K |
| D0274 |
Bitewings - four radiographic images |
681 |
681 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
645 |
645 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
470 |
466 |
$12K |
| D0272 |
Bitewings - two radiographic images |
465 |
465 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
309 |
308 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
117 |
117 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$887.28 |