| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
659 |
442 |
$92K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
727 |
440 |
$74K |
| D1110 |
Prophylaxis - adult |
1,337 |
1,337 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
2,096 |
2,096 |
$45K |
| D1120 |
Prophylaxis - child |
1,443 |
1,443 |
$44K |
| D1206 |
Topical application of fluoride varnish |
2,511 |
2,509 |
$42K |
| D0274 |
Bitewings - four radiographic images |
936 |
936 |
$28K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
896 |
864 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
687 |
687 |
$21K |
| D0330 |
Panoramic radiographic image |
379 |
379 |
$18K |
| D0272 |
Bitewings - two radiographic images |
476 |
476 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
191 |
191 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
366 |
365 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
40 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
40 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
148 |
148 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14 |
12 |
$106.68 |