| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
134 |
98 |
$15K |
| D1120 |
Prophylaxis - child |
306 |
306 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
298 |
298 |
$13K |
| D1206 |
Topical application of fluoride varnish |
306 |
306 |
$10K |
| D0272 |
Bitewings - two radiographic images |
225 |
225 |
$8K |
| D1351 |
Sealant - per tooth |
91 |
28 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
16 |
$2K |
| D0603 |
|
165 |
165 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
51 |
51 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
26 |
$365.00 |