| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
246 |
143 |
$31K |
| D1120 |
Prophylaxis - child |
627 |
617 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
574 |
561 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
214 |
214 |
$13K |
| D0272 |
Bitewings - two radiographic images |
377 |
371 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
559 |
555 |
$11K |
| D0274 |
Bitewings - four radiographic images |
281 |
277 |
$10K |
| D1110 |
Prophylaxis - adult |
125 |
125 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
54 |
$7K |
| D0330 |
Panoramic radiographic image |
126 |
126 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
334 |
331 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
27 |
16 |
$6K |
| D1206 |
Topical application of fluoride varnish |
197 |
194 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
94 |
85 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
241 |
238 |
$3K |
| D1351 |
Sealant - per tooth |
42 |
15 |
$1K |