| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,054 |
1,046 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
1,603 |
1,589 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,753 |
1,740 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
183 |
130 |
$20K |
| D1120 |
Prophylaxis - child |
637 |
637 |
$19K |
| D0274 |
Bitewings - four radiographic images |
560 |
557 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,100 |
1,087 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,021 |
980 |
$8K |
| D0330 |
Panoramic radiographic image |
149 |
149 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
228 |
203 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
39 |
25 |
$6K |
| D0272 |
Bitewings - two radiographic images |
105 |
105 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
28 |
28 |
$790.29 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$704.01 |