| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
115 |
59 |
$14K |
| D1120 |
Prophylaxis - child |
217 |
217 |
$7K |
| D1206 |
Topical application of fluoride varnish |
315 |
315 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
245 |
245 |
$5K |
| D0272 |
Bitewings - two radiographic images |
125 |
125 |
$2K |
| D1110 |
Prophylaxis - adult |
45 |
45 |
$2K |
| D1351 |
Sealant - per tooth |
80 |
29 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
61 |
56 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
18 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
15 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
30 |
30 |
$914.70 |
| D0274 |
Bitewings - four radiographic images |
25 |
25 |
$731.76 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$365.88 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$198.12 |