| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
404 |
168 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
895 |
836 |
$23K |
| D1120 |
Prophylaxis - child |
561 |
528 |
$18K |
| D1110 |
Prophylaxis - adult |
316 |
291 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,024 |
958 |
$13K |
| D1351 |
Sealant - per tooth |
562 |
87 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,241 |
748 |
$12K |
| D0274 |
Bitewings - four radiographic images |
340 |
316 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
950 |
869 |
$10K |
| D0272 |
Bitewings - two radiographic images |
266 |
241 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
39 |
14 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
15 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
26 |
26 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
49 |
48 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
67 |
56 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
15 |
14 |
$494.48 |
| D0240 |
|
27 |
15 |
$205.80 |
| D0603 |
|
1,404 |
1,345 |
$27.01 |