| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
544 |
255 |
$37K |
| D9248 |
|
272 |
251 |
$21K |
| D1120 |
Prophylaxis - child |
695 |
669 |
$20K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
531 |
507 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
104 |
52 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
569 |
548 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
162 |
82 |
$10K |
| D0272 |
Bitewings - two radiographic images |
565 |
542 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
120 |
63 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
320 |
313 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
242 |
233 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
100 |
92 |
$3K |
| D1351 |
Sealant - per tooth |
94 |
26 |
$3K |
| D1206 |
Topical application of fluoride varnish |
142 |
138 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
189 |
178 |
$2K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
102 |
41 |
$875.20 |
| D0330 |
Panoramic radiographic image |
14 |
13 |
$295.88 |
| D1330 |
|
358 |
347 |
$0.00 |