| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
951 |
424 |
$90K |
| D1120 |
Prophylaxis - child |
1,461 |
1,460 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,210 |
1,209 |
$23K |
| D1206 |
Topical application of fluoride varnish |
1,420 |
1,420 |
$22K |
| D0272 |
Bitewings - two radiographic images |
604 |
604 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
182 |
182 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
34 |
12 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
407 |
404 |
$5K |
| D9310 |
|
87 |
87 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
411 |
151 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
26 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
18 |
12 |
$2K |
| D0240 |
|
45 |
41 |
$729.46 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$390.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
536 |
462 |
$0.00 |