| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,545 |
336 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
844 |
302 |
$36K |
| D4341 |
|
1,534 |
372 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
595 |
519 |
$13K |
| D1110 |
Prophylaxis - adult |
455 |
403 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
205 |
113 |
$12K |
| D0330 |
Panoramic radiographic image |
550 |
474 |
$11K |
| D2330 |
|
336 |
112 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
449 |
410 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
461 |
365 |
$7K |
| D0274 |
Bitewings - four radiographic images |
867 |
779 |
$7K |
| D2332 |
|
103 |
51 |
$6K |
| D2331 |
|
159 |
29 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
478 |
437 |
$6K |
| D1206 |
Topical application of fluoride varnish |
470 |
420 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
573 |
508 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
29 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
472 |
307 |
$736.08 |
| D0210 |
Intraoral - complete series of radiographic images |
18 |
17 |
$463.13 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
21 |
14 |
$360.00 |
| D1120 |
Prophylaxis - child |
13 |
12 |
$275.76 |