| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
571 |
350 |
$46K |
| D1120 |
Prophylaxis - child |
1,399 |
1,358 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,299 |
1,254 |
$36K |
| D1206 |
Topical application of fluoride varnish |
1,643 |
1,593 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
587 |
576 |
$25K |
| D0330 |
Panoramic radiographic image |
505 |
486 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
121 |
52 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
862 |
579 |
$15K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
563 |
538 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
713 |
699 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
99 |
74 |
$6K |
| D1110 |
Prophylaxis - adult |
150 |
148 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
71 |
54 |
$5K |
| D0272 |
Bitewings - two radiographic images |
188 |
183 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$409.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$324.00 |