| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
417 |
220 |
$49K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
231 |
107 |
$45K |
| D1120 |
Prophylaxis - child |
655 |
652 |
$26K |
| D1208 |
Topical application of fluoride, excluding varnish |
698 |
696 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
188 |
90 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
523 |
520 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
105 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
61 |
44 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
325 |
137 |
$4K |
| D0272 |
Bitewings - two radiographic images |
188 |
186 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
217 |
213 |
$4K |
| D9310 |
|
41 |
41 |
$3K |
| D9248 |
|
44 |
43 |
$2K |
| D1351 |
Sealant - per tooth |
27 |
14 |
$918.00 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$683.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
89 |
77 |
$0.00 |