| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
333 |
241 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
765 |
664 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
296 |
206 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
533 |
533 |
$13K |
| D1120 |
Prophylaxis - child |
484 |
484 |
$10K |
| D1206 |
Topical application of fluoride varnish |
644 |
644 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
132 |
90 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
709 |
706 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
253 |
237 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
123 |
$5K |
| D1110 |
Prophylaxis - adult |
130 |
130 |
$4K |
| D1351 |
Sealant - per tooth |
106 |
38 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
16 |
$2K |
| D0350 |
|
49 |
46 |
$1K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$1K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$336.00 |
| D9996 |
|
14 |
14 |
$210.00 |