| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
605 |
273 |
$56K |
| D1351 |
Sealant - per tooth |
1,986 |
364 |
$50K |
| D1120 |
Prophylaxis - child |
770 |
733 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
785 |
747 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,789 |
843 |
$19K |
| D0145 |
Oral evaluation for a patient under three years of age |
142 |
135 |
$18K |
| D1206 |
Topical application of fluoride varnish |
954 |
910 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,180 |
1,128 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
471 |
432 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
74 |
$10K |
| D0274 |
Bitewings - four radiographic images |
304 |
293 |
$10K |
| D0272 |
Bitewings - two radiographic images |
436 |
419 |
$9K |
| D1110 |
Prophylaxis - adult |
169 |
160 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
203 |
192 |
$6K |
| D0330 |
Panoramic radiographic image |
91 |
89 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
14 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$176.40 |
| D0601 |
|
125 |
118 |
$0.00 |
| D0603 |
|
1,104 |
1,060 |
$0.00 |