| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
339 |
245 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
540 |
534 |
$13K |
| D1120 |
Prophylaxis - child |
551 |
550 |
$11K |
| D1206 |
Topical application of fluoride varnish |
804 |
798 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
263 |
261 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
178 |
118 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
307 |
287 |
$7K |
| D0272 |
Bitewings - two radiographic images |
448 |
447 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
51 |
38 |
$4K |
| D0274 |
Bitewings - four radiographic images |
170 |
168 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
38 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
90 |
89 |
$2K |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
101 |
101 |
$911.90 |