| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
499 |
266 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
341 |
194 |
$37K |
| D1120 |
Prophylaxis - child |
1,374 |
1,198 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
716 |
702 |
$29K |
| D1206 |
Topical application of fluoride varnish |
873 |
853 |
$20K |
| D1351 |
Sealant - per tooth |
576 |
119 |
$16K |
| D0330 |
Panoramic radiographic image |
277 |
266 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
409 |
378 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
713 |
538 |
$12K |
| D0272 |
Bitewings - two radiographic images |
561 |
510 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
65 |
38 |
$9K |
| D0274 |
Bitewings - four radiographic images |
296 |
287 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
497 |
477 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
72 |
50 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
137 |
132 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
384 |
365 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
146 |
144 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$862.16 |