| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,013 |
934 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
497 |
213 |
$75K |
| D0120 |
Periodic oral evaluation - established patient |
1,161 |
1,078 |
$50K |
| D1120 |
Prophylaxis - child |
793 |
753 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
413 |
162 |
$47K |
| D1206 |
Topical application of fluoride varnish |
1,375 |
1,289 |
$35K |
| D0274 |
Bitewings - four radiographic images |
600 |
559 |
$32K |
| D0220 |
Intraoral - periapical first radiographic image |
505 |
454 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
297 |
276 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
12 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
31 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$781.80 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
13 |
$763.56 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$570.08 |