| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
465 |
238 |
$43K |
| D1120 |
Prophylaxis - child |
681 |
671 |
$31K |
| D1206 |
Topical application of fluoride varnish |
659 |
651 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
275 |
266 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
205 |
202 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
40 |
33 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
193 |
193 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
41 |
$5K |
| D0272 |
Bitewings - two radiographic images |
206 |
204 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
31 |
15 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$560.95 |