| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
169 |
54 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
52 |
12 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
159 |
154 |
$4K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
155 |
142 |
$3K |
| D1120 |
Prophylaxis - child |
66 |
64 |
$1K |
| D1351 |
Sealant - per tooth |
62 |
25 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
130 |
52 |
$989.86 |
| D1208 |
Topical application of fluoride, excluding varnish |
98 |
96 |
$940.80 |
| D0220 |
Intraoral - periapical first radiographic image |
56 |
54 |
$502.40 |
| D0603 |
|
187 |
184 |
$0.00 |