| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
269 |
130 |
$24K |
| D1120 |
Prophylaxis - child |
602 |
602 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
105 |
52 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
634 |
634 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
602 |
602 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
258 |
238 |
$9K |
| D1110 |
Prophylaxis - adult |
180 |
180 |
$8K |
| D1351 |
Sealant - per tooth |
225 |
77 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
93 |
51 |
$7K |
| D9920 |
|
79 |
68 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
75 |
50 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
403 |
312 |
$4K |
| D0272 |
Bitewings - two radiographic images |
216 |
216 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
336 |
333 |
$4K |
| D1206 |
Topical application of fluoride varnish |
179 |
179 |
$4K |
| D0274 |
Bitewings - four radiographic images |
98 |
98 |
$3K |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
77 |
77 |
$2K |
| D3120 |
|
70 |
33 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
21 |
20 |
$521.43 |
| D9994 |
|
163 |
163 |
$124.20 |