| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
512 |
291 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
723 |
723 |
$35K |
| D1120 |
Prophylaxis - child |
737 |
737 |
$33K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
140 |
100 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
138 |
99 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
647 |
647 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
149 |
115 |
$8K |
| D0272 |
Bitewings - two radiographic images |
511 |
511 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
562 |
547 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
74 |
58 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
146 |
146 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
330 |
328 |
$3K |
| D1351 |
Sealant - per tooth |
59 |
29 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$1K |
| D1206 |
Topical application of fluoride varnish |
48 |
48 |
$750.24 |
| D0602 |
|
53 |
53 |
$0.00 |
| D1330 |
|
319 |
319 |
$0.00 |
| D0603 |
|
245 |
245 |
$0.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
19 |
19 |
$0.00 |