| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,233 |
1,210 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
675 |
433 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
1,283 |
1,258 |
$29K |
| D1206 |
Topical application of fluoride varnish |
1,271 |
1,242 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
414 |
257 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
216 |
139 |
$18K |
| D0274 |
Bitewings - four radiographic images |
623 |
610 |
$15K |
| D1120 |
Prophylaxis - child |
405 |
395 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
381 |
373 |
$11K |
| D0330 |
Panoramic radiographic image |
290 |
280 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
252 |
232 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
328 |
325 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
489 |
469 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
379 |
359 |
$3K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$468.61 |