| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,287 |
1,273 |
$134K |
| D1110 |
Prophylaxis - adult |
1,689 |
1,687 |
$118K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
256 |
176 |
$27K |
| D1120 |
Prophylaxis - child |
139 |
139 |
$10K |
| D1206 |
Topical application of fluoride varnish |
249 |
247 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
82 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
922 |
697 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,356 |
1,354 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
1,961 |
1,958 |
$1K |
| D0274 |
Bitewings - four radiographic images |
1,711 |
1,706 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,380 |
1,074 |
$642.12 |
| D0140 |
Limited oral evaluation - problem focused |
24 |
24 |
$524.53 |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$493.93 |
| D0230 |
Intraoral - periapical each additional radiographic image |
171 |
86 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
86 |
86 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$0.00 |