| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
597 |
310 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
423 |
204 |
$23K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
159 |
76 |
$19K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
323 |
322 |
$11K |
| D1120 |
Prophylaxis - child |
337 |
337 |
$11K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
350 |
312 |
$10K |
| D0274 |
Bitewings - four radiographic images |
306 |
306 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
197 |
188 |
$6K |
| D1206 |
Topical application of fluoride varnish |
305 |
304 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
479 |
361 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
68 |
44 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
462 |
457 |
$5K |
| D8660 |
|
33 |
32 |
$3K |
| D0330 |
Panoramic radiographic image |
66 |
65 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
81 |
81 |
$2K |
| D7111 |
|
36 |
25 |
$2K |
| D1351 |
Sealant - per tooth |
57 |
26 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
36 |
36 |
$652.69 |
| D0340 |
|
13 |
12 |
$527.12 |
| D0470 |
|
13 |
12 |
$0.00 |
| D0350 |
|
13 |
12 |
$0.00 |