| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
213 |
109 |
$29K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
79 |
$13K |
| D1120 |
Prophylaxis - child |
256 |
256 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
304 |
304 |
$7K |
| D1206 |
Topical application of fluoride varnish |
395 |
395 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
191 |
180 |
$6K |
| D1110 |
Prophylaxis - adult |
107 |
107 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
35 |
14 |
$4K |
| D1351 |
Sealant - per tooth |
100 |
32 |
$3K |
| D0272 |
Bitewings - two radiographic images |
115 |
115 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
49 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
71 |
71 |
$849.94 |
| D0274 |
Bitewings - four radiographic images |
16 |
16 |
$450.24 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$389.88 |