| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
746 |
409 |
$168K |
| D1120 |
Prophylaxis - child |
981 |
865 |
$45K |
| D1206 |
Topical application of fluoride varnish |
1,604 |
1,366 |
$40K |
| D1351 |
Sealant - per tooth |
1,039 |
229 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
809 |
569 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
878 |
742 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
78 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
373 |
290 |
$23K |
| D1110 |
Prophylaxis - adult |
328 |
298 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
53 |
12 |
$17K |
| D0240 |
|
508 |
233 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
566 |
236 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
476 |
398 |
$9K |
| D0272 |
Bitewings - two radiographic images |
273 |
246 |
$9K |
| D0274 |
Bitewings - four radiographic images |
166 |
148 |
$7K |
| D1354 |
|
151 |
29 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
37 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$849.12 |
| D0350 |
|
19 |
12 |
$453.84 |
| D0603 |
|
1,761 |
1,449 |
$0.00 |
| D0602 |
|
12 |
12 |
$0.00 |
| D9219 |
|
28 |
27 |
$0.00 |