| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9243 |
|
356 |
315 |
$132K |
| D9239 |
|
333 |
312 |
$86K |
| D1110 |
Prophylaxis - adult |
894 |
888 |
$70K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
411 |
181 |
$52K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
175 |
84 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
301 |
119 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
162 |
65 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
98 |
97 |
$9K |
| D1206 |
Topical application of fluoride varnish |
878 |
872 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
522 |
516 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
134 |
134 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
818 |
588 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
638 |
606 |
$2K |
| D0274 |
Bitewings - four radiographic images |
159 |
156 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
47 |
36 |
$356.54 |