| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
467 |
359 |
$33K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,096 |
968 |
$31K |
| D1120 |
Prophylaxis - child |
884 |
871 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,287 |
1,272 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
882 |
875 |
$20K |
| D1110 |
Prophylaxis - adult |
480 |
476 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
295 |
249 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
200 |
112 |
$13K |
| D0274 |
Bitewings - four radiographic images |
447 |
444 |
$12K |
| D0272 |
Bitewings - two radiographic images |
607 |
599 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
331 |
325 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
161 |
153 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
16 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$714.71 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
40 |
$507.18 |
| D9986 |
|
317 |
311 |
$0.00 |