| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,205 |
629 |
$77K |
| D0120 |
Periodic oral evaluation - established patient |
1,725 |
1,636 |
$36K |
| D1120 |
Prophylaxis - child |
1,194 |
1,152 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,811 |
1,730 |
$28K |
| D1110 |
Prophylaxis - adult |
621 |
571 |
$20K |
| D0274 |
Bitewings - four radiographic images |
844 |
809 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,594 |
1,524 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,390 |
1,331 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
171 |
87 |
$9K |
| D0272 |
Bitewings - two radiographic images |
371 |
360 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
65 |
40 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
106 |
83 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
30 |
$654.40 |