| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,309 |
908 |
$141K |
| D1120 |
Prophylaxis - child |
2,337 |
2,330 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
2,207 |
2,200 |
$99K |
| D1206 |
Topical application of fluoride varnish |
2,310 |
2,304 |
$74K |
| D0272 |
Bitewings - two radiographic images |
1,864 |
1,854 |
$62K |
| D1351 |
Sealant - per tooth |
592 |
196 |
$26K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
629 |
608 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
156 |
118 |
$16K |
| D0603 |
|
892 |
890 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
49 |
46 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
551 |
545 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
40 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
13 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
17 |
17 |
$765.00 |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$171.00 |