| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
767 |
475 |
$80K |
| D1120 |
Prophylaxis - child |
1,978 |
1,976 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,830 |
2,827 |
$65K |
| D1206 |
Topical application of fluoride varnish |
2,851 |
2,849 |
$46K |
| D1110 |
Prophylaxis - adult |
775 |
774 |
$39K |
| D1351 |
Sealant - per tooth |
1,005 |
314 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,570 |
1,570 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
339 |
222 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
314 |
267 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
679 |
665 |
$22K |
| D0140 |
Limited oral evaluation - problem focused |
301 |
299 |
$12K |
| D0330 |
Panoramic radiographic image |
200 |
200 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
532 |
522 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
36 |
30 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
306 |
217 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
64 |
64 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
40 |
40 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$326.72 |