| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
894 |
465 |
$67K |
| D1120 |
Prophylaxis - child |
1,355 |
1,354 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
1,511 |
1,511 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,140 |
1,140 |
$15K |
| D0272 |
Bitewings - two radiographic images |
953 |
952 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
185 |
124 |
$10K |
| D1206 |
Topical application of fluoride varnish |
355 |
355 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
80 |
27 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
453 |
450 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
84 |
55 |
$5K |
| D1110 |
Prophylaxis - adult |
70 |
70 |
$4K |
| D1351 |
Sealant - per tooth |
82 |
29 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
14 |
$2K |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$328.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
29 |
$167.05 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
59 |
54 |
$0.00 |
| D1999 |
|
122 |
116 |
$0.00 |
| D1330 |
|
658 |
657 |
$0.00 |
| D0602 |
|
235 |
235 |
$0.00 |
| D0603 |
|
269 |
269 |
$0.00 |
| D1310 |
|
101 |
101 |
$0.00 |