| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
966 |
518 |
$70K |
| D1120 |
Prophylaxis - child |
2,872 |
2,854 |
$65K |
| D0120 |
Periodic oral evaluation - established patient |
3,997 |
3,963 |
$60K |
| D1110 |
Prophylaxis - adult |
2,127 |
2,085 |
$57K |
| D1206 |
Topical application of fluoride varnish |
4,238 |
4,213 |
$56K |
| D9420 |
|
326 |
319 |
$49K |
| D7140 |
Extraction, erupted tooth or exposed root |
755 |
355 |
$41K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
758 |
730 |
$30K |
| D0272 |
Bitewings - two radiographic images |
2,012 |
2,004 |
$27K |
| D1351 |
Sealant - per tooth |
1,092 |
310 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
356 |
220 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
593 |
582 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
76 |
28 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
132 |
129 |
$6K |
| D0240 |
|
421 |
254 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
318 |
314 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28 |
14 |
$173.73 |