| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
396 |
202 |
$29K |
| D1120 |
Prophylaxis - child |
819 |
815 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
391 |
226 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,062 |
1,056 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
553 |
552 |
$16K |
| D1351 |
Sealant - per tooth |
565 |
169 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
662 |
653 |
$15K |
| D1110 |
Prophylaxis - adult |
342 |
336 |
$13K |
| D0330 |
Panoramic radiographic image |
409 |
406 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
290 |
279 |
$8K |
| D9248 |
|
92 |
88 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
77 |
29 |
$8K |
| D0272 |
Bitewings - two radiographic images |
364 |
362 |
$5K |
| D0274 |
Bitewings - four radiographic images |
224 |
224 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
14 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
69 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
71 |
$743.35 |
| D3120 |
|
28 |
12 |
$78.28 |