| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
828 |
519 |
$61K |
| D1120 |
Prophylaxis - child |
1,535 |
1,531 |
$51K |
| D1206 |
Topical application of fluoride varnish |
2,028 |
2,022 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,460 |
1,458 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
485 |
367 |
$30K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
256 |
113 |
$29K |
| D1110 |
Prophylaxis - adult |
698 |
696 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
964 |
917 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
791 |
786 |
$24K |
| D9248 |
|
236 |
233 |
$21K |
| D1351 |
Sealant - per tooth |
619 |
219 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
158 |
107 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,059 |
1,050 |
$13K |
| D0272 |
Bitewings - two radiographic images |
758 |
756 |
$13K |
| D0330 |
Panoramic radiographic image |
332 |
329 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
190 |
115 |
$11K |
| D0274 |
Bitewings - four radiographic images |
394 |
390 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
815 |
757 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
152 |
151 |
$3K |