| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,511 |
873 |
$97K |
| D1351 |
Sealant - per tooth |
2,807 |
844 |
$68K |
| D1120 |
Prophylaxis - child |
2,280 |
2,279 |
$64K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
520 |
258 |
$55K |
| D1206 |
Topical application of fluoride varnish |
2,910 |
2,908 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
2,487 |
2,485 |
$41K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
728 |
507 |
$34K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,379 |
1,328 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
484 |
280 |
$25K |
| D1110 |
Prophylaxis - adult |
598 |
598 |
$24K |
| D0272 |
Bitewings - two radiographic images |
963 |
961 |
$16K |
| D9920 |
|
266 |
263 |
$15K |
| D9994 |
|
2,232 |
2,229 |
$15K |
| D0240 |
|
480 |
267 |
$6K |
| D0274 |
Bitewings - four radiographic images |
184 |
184 |
$6K |
| D0330 |
Panoramic radiographic image |
63 |
63 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
167 |
167 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
113 |
113 |
$4K |
| D9248 |
|
40 |
39 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
217 |
217 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
71 |
71 |
$2K |