| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
400 |
393 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
122 |
72 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
921 |
353 |
$10K |
| D1110 |
Prophylaxis - adult |
181 |
178 |
$9K |
| D1120 |
Prophylaxis - child |
214 |
212 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
55 |
$7K |
| D0274 |
Bitewings - four radiographic images |
203 |
198 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
372 |
366 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
386 |
376 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
24 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
48 |
43 |
$1K |
| D0603 |
|
269 |
267 |
$0.00 |
| D0602 |
|
96 |
91 |
$0.00 |
| D1999 |
|
18 |
15 |
$0.00 |