| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
70 |
42 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
63 |
$13K |
| D1120 |
Prophylaxis - child |
202 |
202 |
$8K |
| D1206 |
Topical application of fluoride varnish |
202 |
202 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
156 |
156 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
43 |
36 |
$4K |
| D0272 |
Bitewings - two radiographic images |
87 |
87 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$2K |
| D0240 |
|
34 |
17 |
$748.00 |
| D0220 |
Intraoral - periapical first radiographic image |
32 |
32 |
$593.26 |