| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,004 |
425 |
$125K |
| D9420 |
|
451 |
443 |
$115K |
| D1120 |
Prophylaxis - child |
3,671 |
3,651 |
$98K |
| D1206 |
Topical application of fluoride varnish |
5,619 |
5,591 |
$92K |
| D7140 |
Extraction, erupted tooth or exposed root |
810 |
283 |
$85K |
| D1110 |
Prophylaxis - adult |
1,633 |
1,630 |
$56K |
| D0272 |
Bitewings - two radiographic images |
2,869 |
2,851 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
2,829 |
2,818 |
$53K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
225 |
86 |
$51K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
882 |
812 |
$41K |
| D1351 |
Sealant - per tooth |
1,582 |
436 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,242 |
1,232 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
260 |
151 |
$21K |
| D0210 |
Intraoral - complete series of radiographic images |
327 |
326 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
538 |
277 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
578 |
573 |
$10K |
| D0240 |
|
339 |
170 |
$6K |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$820.98 |