| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
330 |
200 |
$18K |
| D1120 |
Prophylaxis - child |
562 |
562 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
91 |
46 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
194 |
120 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
392 |
392 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
156 |
81 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
433 |
433 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
108 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
122 |
120 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
69 |
46 |
$2K |
| D1206 |
Topical application of fluoride varnish |
111 |
111 |
$2K |
| D1351 |
Sealant - per tooth |
161 |
39 |
$2K |
| D0603 |
|
143 |
143 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
162 |
160 |
$960.00 |
| D0273 |
|
105 |
105 |
$781.69 |
| D0230 |
Intraoral - periapical each additional radiographic image |
109 |
109 |
$558.00 |
| D0272 |
Bitewings - two radiographic images |
69 |
69 |
$551.50 |
| D0274 |
Bitewings - four radiographic images |
27 |
26 |
$405.00 |
| D0330 |
Panoramic radiographic image |
19 |
19 |
$180.00 |