| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
255 |
252 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
162 |
100 |
$10K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
206 |
202 |
$8K |
| D1120 |
Prophylaxis - child |
255 |
254 |
$7K |
| D1206 |
Topical application of fluoride varnish |
250 |
250 |
$3K |
| D0272 |
Bitewings - two radiographic images |
189 |
188 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
20 |
12 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
421 |
199 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
14 |
$1K |
| D0350 |
|
61 |
38 |
$333.60 |