| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
973 |
535 |
$97K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
602 |
351 |
$82K |
| D1110 |
Prophylaxis - adult |
1,053 |
1,053 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,962 |
1,962 |
$38K |
| D1120 |
Prophylaxis - child |
941 |
941 |
$26K |
| D1320 |
|
789 |
771 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,687 |
1,687 |
$23K |
| D0274 |
Bitewings - four radiographic images |
442 |
442 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
458 |
427 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
495 |
473 |
$7K |
| D0272 |
Bitewings - two radiographic images |
272 |
272 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
77 |
77 |
$2K |
| D1206 |
Topical application of fluoride varnish |
88 |
88 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
172 |
165 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$348.03 |