| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
231 |
116 |
$27K |
| D1120 |
Prophylaxis - child |
678 |
675 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
127 |
70 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
706 |
703 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
564 |
562 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
98 |
53 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
128 |
128 |
$8K |
| D0272 |
Bitewings - two radiographic images |
308 |
308 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
85 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
143 |
142 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
13 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
87 |
66 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$528.00 |
| D0240 |
|
24 |
13 |
$425.19 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
60 |
56 |
$0.00 |