| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
499 |
291 |
$35K |
| D1120 |
Prophylaxis - child |
746 |
745 |
$32K |
| D1206 |
Topical application of fluoride varnish |
660 |
659 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
640 |
640 |
$16K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
599 |
568 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
113 |
82 |
$6K |
| D0272 |
Bitewings - two radiographic images |
438 |
438 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
13 |
12 |
$1K |
| D0240 |
|
69 |
69 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
113 |
111 |
$560.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$540.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$350.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
70 |
$261.00 |
| D0603 |
|
15 |
15 |
$130.00 |