| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
128 |
50 |
$12K |
| D1120 |
Prophylaxis - child |
250 |
245 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
274 |
265 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
177 |
171 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
44 |
12 |
$6K |
| D0272 |
Bitewings - two radiographic images |
129 |
127 |
$4K |
| D9310 |
|
87 |
85 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
42 |
12 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
96 |
93 |
$3K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
28 |
27 |
$2K |
| D1110 |
Prophylaxis - adult |
30 |
26 |
$1K |
| D0240 |
|
13 |
13 |
$326.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
12 |
$228.00 |