| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
801 |
361 |
$64K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
836 |
390 |
$58K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,516 |
1,510 |
$52K |
| D1110 |
Prophylaxis - adult |
554 |
550 |
$24K |
| D1120 |
Prophylaxis - child |
711 |
710 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,214 |
1,213 |
$22K |
| D0274 |
Bitewings - four radiographic images |
590 |
587 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
246 |
95 |
$16K |
| D4346 |
|
132 |
132 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,305 |
1,287 |
$14K |
| D0210 |
Intraoral - complete series of radiographic images |
265 |
263 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,117 |
1,036 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
174 |
104 |
$9K |
| D9110 |
|
136 |
131 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
251 |
251 |
$5K |
| D2394 |
|
20 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
69 |
16 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$739.09 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
16 |
12 |
$419.36 |
| D0270 |
|
29 |
29 |
$283.56 |