| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
366 |
139 |
$20K |
| D1120 |
Prophylaxis - child |
469 |
418 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
411 |
383 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
66 |
16 |
$4K |
| D1206 |
Topical application of fluoride varnish |
340 |
296 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
151 |
135 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
216 |
201 |
$3K |
| D0272 |
Bitewings - two radiographic images |
190 |
175 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
28 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
174 |
136 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
141 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
15 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
20 |
18 |
$780.00 |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
44 |
$429.00 |