| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
526 |
355 |
$57K |
| D1120 |
Prophylaxis - child |
542 |
542 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
474 |
474 |
$21K |
| D1206 |
Topical application of fluoride varnish |
544 |
544 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
159 |
124 |
$16K |
| D0272 |
Bitewings - two radiographic images |
448 |
448 |
$15K |
| D1351 |
Sealant - per tooth |
332 |
138 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
70 |
65 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
91 |
81 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
51 |
38 |
$6K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
237 |
228 |
$6K |
| D2332 |
|
30 |
28 |
$3K |
| D0603 |
|
289 |
289 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
60 |
$3K |
| D9920 |
|
46 |
46 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
137 |
136 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$900.00 |
| D0240 |
|
39 |
39 |
$712.00 |
| D9430 |
|
12 |
12 |
$280.00 |