| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
569 |
299 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
903 |
903 |
$82K |
| D1120 |
Prophylaxis - child |
1,214 |
1,211 |
$76K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
256 |
115 |
$64K |
| D1206 |
Topical application of fluoride varnish |
1,231 |
1,228 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
324 |
205 |
$48K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
515 |
457 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
337 |
336 |
$27K |
| D1351 |
Sealant - per tooth |
375 |
155 |
$19K |
| D0272 |
Bitewings - two radiographic images |
425 |
425 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
115 |
72 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
601 |
584 |
$15K |
| D1110 |
Prophylaxis - adult |
122 |
122 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
686 |
477 |
$13K |
| D0240 |
|
288 |
152 |
$10K |
| D0274 |
Bitewings - four radiographic images |
149 |
149 |
$9K |
| D0603 |
|
729 |
726 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
113 |
111 |
$8K |
| D1354 |
|
407 |
88 |
$7K |
| D0330 |
Panoramic radiographic image |
69 |
68 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
62 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$5K |