| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
681 |
348 |
$63K |
| D1120 |
Prophylaxis - child |
1,604 |
1,570 |
$54K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
232 |
107 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,283 |
1,257 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
521 |
519 |
$32K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
726 |
645 |
$28K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
343 |
243 |
$23K |
| D1206 |
Topical application of fluoride varnish |
899 |
877 |
$20K |
| D0272 |
Bitewings - two radiographic images |
920 |
903 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
927 |
912 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
161 |
73 |
$16K |
| D0145 |
Oral evaluation for a patient under three years of age |
307 |
303 |
$14K |
| D1351 |
Sealant - per tooth |
192 |
71 |
$6K |
| D1110 |
Prophylaxis - adult |
135 |
131 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
615 |
523 |
$6K |
| D9420 |
|
53 |
53 |
$5K |
| D0330 |
Panoramic radiographic image |
72 |
72 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
211 |
180 |
$2K |
| D9248 |
|
16 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
76 |
30 |
$537.92 |
| D9986 |
|
35 |
35 |
$0.00 |
| D9210 |
|
279 |
246 |
$0.00 |
| D0240 |
|
31 |
14 |
$0.00 |