| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
163 |
82 |
$12K |
| D1120 |
Prophylaxis - child |
167 |
139 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
120 |
102 |
$4K |
| D1206 |
Topical application of fluoride varnish |
159 |
134 |
$4K |
| D1351 |
Sealant - per tooth |
126 |
28 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
27 |
$3K |
| D0272 |
Bitewings - two radiographic images |
111 |
94 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
147 |
106 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
77 |
64 |
$870.00 |
| D0603 |
|
141 |
116 |
$625.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$450.00 |
| D1354 |
|
49 |
12 |
$410.00 |