| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
163 |
98 |
$390.88 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,069 |
1,066 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
963 |
963 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
982 |
980 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
663 |
662 |
$0.00 |
| D0602 |
|
58 |
58 |
$0.00 |
| D0601 |
|
305 |
301 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
17 |
12 |
$0.00 |
| D0603 |
|
13 |
13 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
1,091 |
1,086 |
$0.00 |
| D1110 |
Prophylaxis - adult |
79 |
79 |
$0.00 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
214 |
47 |
$0.00 |
| D1120 |
Prophylaxis - child |
861 |
859 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
107 |
107 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
54 |
52 |
$0.00 |