| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
894 |
356 |
$94K |
| D1120 |
Prophylaxis - child |
1,855 |
1,786 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
945 |
885 |
$41K |
| D1206 |
Topical application of fluoride varnish |
2,150 |
2,074 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,533 |
847 |
$28K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
196 |
45 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
980 |
966 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
594 |
519 |
$25K |
| D1351 |
Sealant - per tooth |
736 |
155 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,024 |
962 |
$15K |
| D1110 |
Prophylaxis - adult |
281 |
274 |
$11K |
| D0240 |
|
571 |
273 |
$9K |
| D0145 |
Oral evaluation for a patient under three years of age |
222 |
218 |
$8K |
| D0272 |
Bitewings - two radiographic images |
429 |
409 |
$7K |
| D0330 |
Panoramic radiographic image |
123 |
121 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
98 |
46 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
116 |
113 |
$4K |
| D9420 |
|
17 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
49 |
48 |
$2K |