| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
483 |
329 |
$50K |
| D1120 |
Prophylaxis - child |
864 |
861 |
$38K |
| D1351 |
Sealant - per tooth |
847 |
228 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
753 |
751 |
$33K |
| D1206 |
Topical application of fluoride varnish |
871 |
869 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
173 |
111 |
$21K |
| D0272 |
Bitewings - two radiographic images |
472 |
470 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
439 |
420 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
74 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
40 |
30 |
$7K |
| D0603 |
|
296 |
294 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
204 |
201 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
65 |
65 |
$3K |
| D9920 |
|
62 |
58 |
$3K |
| D0330 |
Panoramic radiographic image |
19 |
19 |
$1K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$503.25 |