| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,180 |
604 |
$128K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
577 |
199 |
$83K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,541 |
1,503 |
$69K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,198 |
1,094 |
$54K |
| D1120 |
Prophylaxis - child |
1,943 |
1,913 |
$54K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,132 |
1,509 |
$48K |
| D1351 |
Sealant - per tooth |
1,598 |
439 |
$45K |
| D1206 |
Topical application of fluoride varnish |
2,531 |
2,490 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
401 |
253 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
461 |
210 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,019 |
1,016 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,797 |
1,728 |
$27K |
| D1110 |
Prophylaxis - adult |
484 |
478 |
$19K |
| D0330 |
Panoramic radiographic image |
154 |
149 |
$9K |
| D0272 |
Bitewings - two radiographic images |
411 |
406 |
$8K |
| D0145 |
Oral evaluation for a patient under three years of age |
156 |
154 |
$6K |
| D0274 |
Bitewings - four radiographic images |
171 |
169 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
136 |
132 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
14 |
$3K |
| D9420 |
|
12 |
12 |
$1K |