| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
606 |
204 |
$52K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
377 |
94 |
$48K |
| D1120 |
Prophylaxis - child |
738 |
708 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
857 |
820 |
$23K |
| D0145 |
Oral evaluation for a patient under three years of age |
161 |
154 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,992 |
803 |
$21K |
| D9248 |
|
209 |
181 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
282 |
91 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
884 |
845 |
$12K |
| D0272 |
Bitewings - two radiographic images |
557 |
528 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
915 |
855 |
$10K |
| D1110 |
Prophylaxis - adult |
143 |
136 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
315 |
281 |
$5K |
| D1351 |
Sealant - per tooth |
163 |
40 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
26 |
12 |
$2K |
| D7111 |
|
48 |
16 |
$458.80 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$187.80 |
| D0601 |
|
538 |
522 |
$0.00 |
| D0603 |
|
201 |
194 |
$0.00 |
| D0602 |
|
291 |
279 |
$0.00 |