| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
468 |
202 |
$45K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
270 |
76 |
$43K |
| D1120 |
Prophylaxis - child |
1,257 |
1,184 |
$40K |
| D1206 |
Topical application of fluoride varnish |
1,487 |
1,381 |
$38K |
| D1351 |
Sealant - per tooth |
1,085 |
282 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,070 |
995 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
406 |
328 |
$15K |
| D0272 |
Bitewings - two radiographic images |
847 |
800 |
$13K |
| D1110 |
Prophylaxis - adult |
212 |
189 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
195 |
$6K |
| D0274 |
Bitewings - four radiographic images |
254 |
231 |
$5K |
| D0330 |
Panoramic radiographic image |
152 |
140 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
78 |
73 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
547 |
276 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
364 |
337 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
26 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$803.88 |
| D1330 |
|
17 |
17 |
$0.00 |
| D0603 |
|
13 |
13 |
$0.00 |