| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
41 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
19 |
$3K |
| D1120 |
Prophylaxis - child |
81 |
80 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
85 |
79 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
250 |
87 |
$2K |
| D1206 |
Topical application of fluoride varnish |
96 |
95 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
17 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
62 |
62 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
96 |
93 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
36 |
34 |
$965.25 |
| D1351 |
Sealant - per tooth |
31 |
14 |
$908.30 |
| D1110 |
Prophylaxis - adult |
20 |
19 |
$789.84 |
| D0272 |
Bitewings - two radiographic images |
43 |
42 |
$704.14 |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$664.23 |
| D0274 |
Bitewings - four radiographic images |
21 |
20 |
$493.40 |