| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
753 |
327 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
767 |
757 |
$50K |
| D1120 |
Prophylaxis - child |
701 |
688 |
$30K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
568 |
529 |
$20K |
| D1351 |
Sealant - per tooth |
449 |
116 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
482 |
477 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
567 |
555 |
$13K |
| D0272 |
Bitewings - two radiographic images |
396 |
391 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
47 |
26 |
$9K |
| D1206 |
Topical application of fluoride varnish |
154 |
154 |
$4K |
| D1330 |
|
72 |
72 |
$432.00 |