| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
597 |
303 |
$32K |
| D1120 |
Prophylaxis - child |
1,428 |
1,408 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,724 |
1,701 |
$20K |
| D9248 |
|
275 |
245 |
$19K |
| D9920 |
|
612 |
592 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
1,311 |
1,298 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,226 |
838 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
396 |
383 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
87 |
53 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,190 |
1,140 |
$8K |
| D1110 |
Prophylaxis - adult |
279 |
274 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
349 |
323 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
149 |
88 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
40 |
24 |
$7K |
| D0272 |
Bitewings - two radiographic images |
571 |
563 |
$6K |
| D3240 |
|
17 |
12 |
$5K |
| D9310 |
|
42 |
41 |
$4K |
| D0240 |
|
315 |
163 |
$1K |
| D9630 |
|
622 |
610 |
$981.54 |
| D0140 |
Limited oral evaluation - problem focused |
25 |
24 |
$774.72 |
| D0274 |
Bitewings - four radiographic images |
74 |
74 |
$430.56 |
| D0330 |
Panoramic radiographic image |
28 |
28 |
$0.00 |