| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
53 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
161 |
151 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
56 |
41 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
106 |
100 |
$5K |
| D1110 |
Prophylaxis - adult |
42 |
39 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
77 |
73 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
71 |
68 |
$1K |
| D9630 |
|
56 |
55 |
$848.00 |
| D1120 |
Prophylaxis - child |
17 |
16 |
$704.00 |
| D0272 |
Bitewings - two radiographic images |
26 |
26 |
$467.50 |
| D0274 |
Bitewings - four radiographic images |
26 |
25 |
$447.70 |