| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,236 |
509 |
$106K |
| D1120 |
Prophylaxis - child |
2,794 |
2,794 |
$79K |
| D0120 |
Periodic oral evaluation - established patient |
3,666 |
3,655 |
$73K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
568 |
201 |
$61K |
| D1206 |
Topical application of fluoride varnish |
3,656 |
3,641 |
$54K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,745 |
1,673 |
$42K |
| D9310 |
|
716 |
716 |
$33K |
| D0272 |
Bitewings - two radiographic images |
1,313 |
1,313 |
$22K |
| D1110 |
Prophylaxis - adult |
375 |
372 |
$16K |
| D1351 |
Sealant - per tooth |
268 |
91 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
50 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
309 |
309 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
25 |
$2K |
| D9248 |
|
14 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
36 |
35 |
$987.00 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
15 |
$213.36 |