| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
587 |
379 |
$58K |
| D1110 |
Prophylaxis - adult |
821 |
802 |
$38K |
| D1120 |
Prophylaxis - child |
1,090 |
1,051 |
$36K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
786 |
756 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,103 |
1,074 |
$29K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
807 |
753 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,223 |
1,166 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,243 |
1,197 |
$23K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
131 |
75 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
239 |
163 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
694 |
640 |
$9K |
| D1206 |
Topical application of fluoride varnish |
267 |
265 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
44 |
31 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
291 |
266 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
70 |
$2K |
| D7111 |
|
20 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$647.98 |
| D9986 |
|
372 |
362 |
$0.00 |