| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
2,281 |
2,281 |
$115K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
556 |
217 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
2,168 |
2,168 |
$50K |
| D0274 |
Bitewings - four radiographic images |
1,593 |
1,593 |
$43K |
| D0330 |
Panoramic radiographic image |
791 |
791 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,880 |
1,880 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
697 |
697 |
$28K |
| D1120 |
Prophylaxis - child |
369 |
369 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
156 |
74 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
686 |
676 |
$8K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
65 |
61 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
39 |
39 |
$1K |
| D0272 |
Bitewings - two radiographic images |
52 |
52 |
$984.88 |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
45 |
$458.35 |