| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
632 |
325 |
$34K |
| D1120 |
Prophylaxis - child |
6,402 |
5,350 |
$19K |
| D0272 |
Bitewings - two radiographic images |
3,991 |
3,371 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
1,726 |
1,367 |
$7K |
| D1206 |
Topical application of fluoride varnish |
2,517 |
2,121 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
26 |
12 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,439 |
1,132 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
24 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
282 |
200 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
609 |
346 |
$3K |
| D1351 |
Sealant - per tooth |
1,230 |
414 |
$3K |
| D0603 |
|
5,355 |
4,424 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
5,473 |
4,616 |
$3K |
| D1330 |
|
7,637 |
6,353 |
$782.17 |
| D1354 |
|
2,908 |
440 |
$264.35 |
| D1208 |
Topical application of fluoride, excluding varnish |
3,383 |
2,854 |
$196.88 |
| D0602 |
|
434 |
431 |
$88.40 |
| D1310 |
|
647 |
520 |
$0.00 |
| D0601 |
|
474 |
378 |
$0.00 |
| D9995 |
|
15 |
15 |
$0.00 |
| D0191 |
|
1,209 |
1,029 |
$0.00 |