| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
200 |
146 |
$14K |
| D1120 |
Prophylaxis - child |
291 |
291 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
89 |
77 |
$9K |
| D1206 |
Topical application of fluoride varnish |
279 |
279 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
250 |
250 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
77 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
201 |
192 |
$5K |
| D0272 |
Bitewings - two radiographic images |
204 |
204 |
$2K |
| D0603 |
|
164 |
164 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
200 |
200 |
$1K |
| D1351 |
Sealant - per tooth |
42 |
12 |
$840.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
139 |
139 |
$531.00 |