| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
1,928 |
956 |
$215K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,407 |
793 |
$125K |
| D1120 |
Prophylaxis - child |
3,682 |
3,651 |
$113K |
| D1206 |
Topical application of fluoride varnish |
4,915 |
4,874 |
$94K |
| D0120 |
Periodic oral evaluation - established patient |
3,862 |
3,821 |
$71K |
| D1110 |
Prophylaxis - adult |
1,658 |
1,647 |
$71K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,430 |
1,427 |
$43K |
| D0274 |
Bitewings - four radiographic images |
1,499 |
1,486 |
$38K |
| D0210 |
Intraoral - complete series of radiographic images |
948 |
918 |
$37K |
| D2394 |
|
207 |
142 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
157 |
98 |
$12K |
| D0272 |
Bitewings - two radiographic images |
605 |
603 |
$11K |
| D0330 |
Panoramic radiographic image |
100 |
100 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
595 |
306 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
487 |
480 |
$4K |
| D1354 |
|
116 |
51 |
$964.80 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
12 |
12 |
$404.88 |