| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
83 |
39 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
12 |
$3K |
| D1120 |
Prophylaxis - child |
85 |
77 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
72 |
63 |
$2K |
| D0274 |
Bitewings - four radiographic images |
61 |
57 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
63 |
53 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
184 |
87 |
$2K |
| D1206 |
Topical application of fluoride varnish |
80 |
74 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
116 |
$1K |