| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
588 |
325 |
$58K |
| D1120 |
Prophylaxis - child |
1,558 |
1,423 |
$46K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
917 |
800 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
1,227 |
1,163 |
$29K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
195 |
68 |
$25K |
| D1206 |
Topical application of fluoride varnish |
1,398 |
1,353 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
373 |
329 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,086 |
1,012 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
122 |
59 |
$13K |
| D0272 |
Bitewings - two radiographic images |
742 |
685 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
999 |
740 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
406 |
312 |
$5K |
| D0330 |
Panoramic radiographic image |
129 |
97 |
$4K |
| D1110 |
Prophylaxis - adult |
67 |
65 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
24 |
$3K |
| D1351 |
Sealant - per tooth |
60 |
25 |
$2K |