| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
594 |
278 |
$98K |
| D1120 |
Prophylaxis - child |
951 |
903 |
$57K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
433 |
221 |
$57K |
| D1351 |
Sealant - per tooth |
1,187 |
238 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
912 |
865 |
$41K |
| D0272 |
Bitewings - two radiographic images |
599 |
571 |
$23K |
| D9211 |
|
331 |
306 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
155 |
87 |
$19K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
349 |
324 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
526 |
501 |
$14K |
| D1206 |
Topical application of fluoride varnish |
545 |
511 |
$14K |
| D1110 |
Prophylaxis - adult |
123 |
116 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
152 |
145 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
124 |
118 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
31 |
13 |
$5K |
| D0240 |
|
101 |
51 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
43 |
42 |
$2K |
| D0274 |
Bitewings - four radiographic images |
18 |
17 |
$964.32 |
| D0220 |
Intraoral - periapical first radiographic image |
39 |
38 |
$879.48 |