| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
79 |
$17K |
| D1120 |
Prophylaxis - child |
481 |
396 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
635 |
508 |
$13K |
| D1206 |
Topical application of fluoride varnish |
605 |
478 |
$11K |
| D1351 |
Sealant - per tooth |
293 |
89 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
54 |
13 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
126 |
107 |
$4K |
| D1310 |
|
155 |
125 |
$4K |
| D0240 |
|
174 |
144 |
$3K |
| D1110 |
Prophylaxis - adult |
145 |
99 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
201 |
165 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
34 |
18 |
$3K |
| D0272 |
Bitewings - two radiographic images |
114 |
98 |
$2K |
| D1330 |
|
155 |
125 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
39 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
12 |
$2K |
| D1353 |
|
55 |
17 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
112 |
87 |
$1K |
| D0425 |
|
47 |
33 |
$938.56 |
| D0274 |
Bitewings - four radiographic images |
54 |
36 |
$768.38 |
| D0330 |
Panoramic radiographic image |
15 |
12 |
$736.68 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
18 |
$705.60 |
| D0601 |
|
28 |
17 |
$198.40 |