| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
508 |
264 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
1,763 |
1,568 |
$38K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
263 |
132 |
$33K |
| D1110 |
Prophylaxis - adult |
834 |
746 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,216 |
1,061 |
$28K |
| D1351 |
Sealant - per tooth |
953 |
162 |
$21K |
| D1120 |
Prophylaxis - child |
770 |
670 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,593 |
1,419 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,449 |
1,286 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
172 |
104 |
$12K |
| D1206 |
Topical application of fluoride varnish |
992 |
892 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
297 |
264 |
$7K |
| D0272 |
Bitewings - two radiographic images |
255 |
221 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
290 |
252 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
34 |
27 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$184.04 |
| D0603 |
|
950 |
920 |
$0.00 |
| D0601 |
|
153 |
146 |
$0.00 |
| D0602 |
|
237 |
229 |
$0.00 |