| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
182 |
124 |
$16K |
| D1120 |
Prophylaxis - child |
399 |
385 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
104 |
68 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
438 |
417 |
$11K |
| D1351 |
Sealant - per tooth |
415 |
108 |
$11K |
| D1206 |
Topical application of fluoride varnish |
489 |
468 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
276 |
246 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
620 |
283 |
$6K |
| D0272 |
Bitewings - two radiographic images |
291 |
278 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
369 |
354 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
27 |
20 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$765.94 |
| D9986 |
|
87 |
83 |
$0.00 |
| D0603 |
|
572 |
556 |
$0.00 |