| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
451 |
352 |
$47K |
| D2394 |
|
436 |
300 |
$46K |
| D1110 |
Prophylaxis - adult |
746 |
726 |
$33K |
| D4341 |
|
722 |
221 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
751 |
734 |
$22K |
| D1206 |
Topical application of fluoride varnish |
834 |
815 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
214 |
173 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
352 |
340 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
256 |
245 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
694 |
639 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
66 |
42 |
$4K |
| D0274 |
Bitewings - four radiographic images |
252 |
244 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
53 |
52 |
$2K |
| D4910 |
|
39 |
38 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
429 |
389 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
51 |
49 |
$842.88 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$275.76 |