| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
871 |
867 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
763 |
760 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,459 |
995 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
274 |
216 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
181 |
162 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
466 |
465 |
$12K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
432 |
410 |
$11K |
| D1351 |
Sealant - per tooth |
232 |
113 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
228 |
170 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
351 |
349 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,106 |
1,096 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
127 |
100 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
89 |
81 |
$5K |
| D0274 |
Bitewings - four radiographic images |
174 |
174 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
86 |
84 |
$1K |
| D1510 |
|
12 |
12 |
$847.20 |