| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D4346 |
|
510 |
510 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
602 |
248 |
$45K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,203 |
1,202 |
$42K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
384 |
165 |
$34K |
| D0274 |
Bitewings - four radiographic images |
844 |
844 |
$25K |
| D1120 |
Prophylaxis - child |
586 |
585 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,200 |
1,196 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
215 |
204 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,095 |
1,059 |
$10K |
| D1206 |
Topical application of fluoride varnish |
367 |
367 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
52 |
$6K |
| D1110 |
Prophylaxis - adult |
128 |
128 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
208 |
205 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
156 |
156 |
$4K |
| D9110 |
|
33 |
33 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
15 |
$413.48 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$383.78 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$150.31 |