| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
320 |
159 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
589 |
450 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
229 |
120 |
$19K |
| D1120 |
Prophylaxis - child |
603 |
466 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
289 |
265 |
$12K |
| D0140 |
Limited oral evaluation - problem focused |
293 |
231 |
$9K |
| D1351 |
Sealant - per tooth |
332 |
109 |
$8K |
| D1206 |
Topical application of fluoride varnish |
630 |
492 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
565 |
441 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
37 |
28 |
$6K |
| D0272 |
Bitewings - two radiographic images |
401 |
322 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
51 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
463 |
361 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
62 |
62 |
$2K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$991.20 |