| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
461 |
433 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
418 |
154 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
544 |
498 |
$9K |
| D9248 |
|
132 |
94 |
$9K |
| D0272 |
Bitewings - two radiographic images |
441 |
416 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
127 |
41 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
194 |
42 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
935 |
593 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
32 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
171 |
112 |
$2K |
| D1351 |
Sealant - per tooth |
51 |
13 |
$942.80 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$930.72 |