| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
593 |
311 |
$64K |
| D1120 |
Prophylaxis - child |
1,324 |
1,271 |
$35K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
731 |
647 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
566 |
524 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
883 |
874 |
$23K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,970 |
574 |
$21K |
| D1206 |
Topical application of fluoride varnish |
975 |
918 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
83 |
15 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
798 |
735 |
$11K |
| D1351 |
Sealant - per tooth |
394 |
120 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
501 |
497 |
$9K |
| D1110 |
Prophylaxis - adult |
117 |
113 |
$4K |
| D0272 |
Bitewings - two radiographic images |
178 |
172 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
81 |
76 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$3K |
| D9420 |
|
14 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
12 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
12 |
$743.40 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$456.12 |