| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,408 |
710 |
$93K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
590 |
301 |
$60K |
| D1120 |
Prophylaxis - child |
2,958 |
2,890 |
$55K |
| D1206 |
Topical application of fluoride varnish |
3,580 |
3,504 |
$42K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,719 |
1,656 |
$42K |
| D0240 |
|
3,957 |
2,057 |
$32K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,360 |
1,310 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
2,010 |
1,988 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
273 |
169 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,200 |
1,164 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
290 |
156 |
$13K |
| D0330 |
Panoramic radiographic image |
328 |
322 |
$12K |
| D1351 |
Sealant - per tooth |
830 |
268 |
$12K |
| D1110 |
Prophylaxis - adult |
329 |
328 |
$6K |
| D9994 |
|
714 |
701 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
764 |
756 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
191 |
187 |
$3K |
| D3120 |
|
421 |
233 |
$3K |
| D9310 |
|
125 |
125 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
286 |
169 |
$707.69 |
| D0274 |
Bitewings - four radiographic images |
49 |
48 |
$461.78 |
| D9992 |
|
102 |
102 |
$298.08 |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$34.58 |
| D9630 |
|
46 |
46 |
$0.00 |