| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
984 |
486 |
$117K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
760 |
335 |
$76K |
| D1110 |
Prophylaxis - adult |
1,118 |
1,037 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,003 |
914 |
$39K |
| D0330 |
Panoramic radiographic image |
562 |
500 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
735 |
696 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
532 |
429 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,366 |
1,221 |
$19K |
| D0274 |
Bitewings - four radiographic images |
666 |
600 |
$19K |
| D4355 |
|
298 |
272 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,335 |
1,099 |
$16K |
| D1120 |
Prophylaxis - child |
601 |
549 |
$15K |
| D1206 |
Topical application of fluoride varnish |
768 |
717 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
410 |
383 |
$10K |
| D1351 |
Sealant - per tooth |
199 |
42 |
$5K |
| D2332 |
|
47 |
26 |
$4K |
| D2394 |
|
24 |
15 |
$3K |
| D2330 |
|
28 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
91 |
85 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
62 |
53 |
$857.05 |