| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
258 |
103 |
$256.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
168 |
47 |
$246.00 |
| D1120 |
Prophylaxis - child |
714 |
649 |
$208.88 |
| D0120 |
Periodic oral evaluation - established patient |
630 |
581 |
$114.02 |
| D0210 |
Intraoral - complete series of radiographic images |
138 |
113 |
$94.00 |
| D1206 |
Topical application of fluoride varnish |
579 |
555 |
$79.35 |
| D0272 |
Bitewings - two radiographic images |
528 |
476 |
$62.91 |
| D0220 |
Intraoral - periapical first radiographic image |
666 |
611 |
$53.02 |
| D0230 |
Intraoral - periapical each additional radiographic image |
667 |
573 |
$35.70 |
| D1208 |
Topical application of fluoride, excluding varnish |
147 |
113 |
$15.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
108 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
30 |
29 |
$0.00 |
| D0240 |
|
35 |
12 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
20 |
12 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
144 |
73 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
161 |
138 |
$0.00 |
| D1110 |
Prophylaxis - adult |
17 |
15 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
34 |
32 |
$0.00 |