| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
758 |
355 |
$86K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
309 |
130 |
$66K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
874 |
852 |
$52K |
| D7140 |
Extraction, erupted tooth or exposed root |
348 |
172 |
$36K |
| D1120 |
Prophylaxis - child |
852 |
836 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
529 |
496 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
265 |
175 |
$25K |
| D9420 |
|
171 |
169 |
$18K |
| D0272 |
Bitewings - two radiographic images |
645 |
632 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
534 |
533 |
$14K |
| D1351 |
Sealant - per tooth |
354 |
138 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
137 |
136 |
$9K |
| D1206 |
Topical application of fluoride varnish |
323 |
311 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
184 |
181 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
326 |
293 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
145 |
139 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
126 |
83 |
$1K |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$975.00 |
| D9986 |
|
138 |
138 |
$0.00 |