| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
410 |
171 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
1,087 |
1,044 |
$24K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
223 |
56 |
$23K |
| D1120 |
Prophylaxis - child |
716 |
691 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,195 |
1,152 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,299 |
1,249 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,771 |
1,215 |
$11K |
| D1110 |
Prophylaxis - adult |
248 |
240 |
$10K |
| D9248 |
|
108 |
103 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
147 |
70 |
$9K |
| D0274 |
Bitewings - four radiographic images |
397 |
379 |
$8K |
| D0272 |
Bitewings - two radiographic images |
402 |
388 |
$7K |
| D1351 |
Sealant - per tooth |
285 |
79 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
33 |
33 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
132 |
120 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
37 |
35 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
19 |
$406.18 |
| D0603 |
|
1,170 |
1,133 |
$0.00 |
| D0602 |
|
13 |
13 |
$0.00 |