| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
742 |
742 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
1,347 |
1,347 |
$27K |
| D1206 |
Topical application of fluoride varnish |
1,396 |
1,396 |
$22K |
| D0274 |
Bitewings - four radiographic images |
604 |
604 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
1,009 |
991 |
$15K |
| D0330 |
Panoramic radiographic image |
302 |
302 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
109 |
63 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
366 |
366 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
358 |
357 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
395 |
320 |
$10K |
| D1120 |
Prophylaxis - child |
288 |
288 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
316 |
187 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
72 |
72 |
$1K |
| D0602 |
|
45 |
45 |
$405.15 |
| D0603 |
|
12 |
12 |
$109.80 |