| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
347 |
343 |
$12K |
| D1120 |
Prophylaxis - child |
324 |
324 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
485 |
483 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
156 |
95 |
$9K |
| D1206 |
Topical application of fluoride varnish |
425 |
423 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
45 |
$4K |
| D0274 |
Bitewings - four radiographic images |
115 |
113 |
$3K |
| D0330 |
Panoramic radiographic image |
81 |
79 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
139 |
136 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
28 |
$1K |
| D0272 |
Bitewings - two radiographic images |
48 |
48 |
$768.00 |
| D0220 |
Intraoral - periapical first radiographic image |
38 |
38 |
$252.54 |