| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
118 |
72 |
$13K |
| D1120 |
Prophylaxis - child |
319 |
319 |
$13K |
| D1206 |
Topical application of fluoride varnish |
327 |
327 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
80 |
60 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
34 |
27 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
171 |
171 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
73 |
73 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
48 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
136 |
136 |
$3K |
| D0272 |
Bitewings - two radiographic images |
93 |
93 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
153 |
73 |
$2K |
| D0240 |
|
24 |
12 |
$443.96 |