| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,277 |
2,248 |
$95K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,817 |
2,773 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
768 |
428 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
2,360 |
2,348 |
$68K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
330 |
115 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
3,008 |
2,957 |
$43K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,703 |
1,695 |
$35K |
| D0272 |
Bitewings - two radiographic images |
1,188 |
1,180 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
283 |
86 |
$25K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
753 |
674 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
166 |
79 |
$14K |
| D0274 |
Bitewings - four radiographic images |
425 |
420 |
$14K |
| D1110 |
Prophylaxis - adult |
156 |
156 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
67 |
55 |
$5K |
| D1351 |
Sealant - per tooth |
161 |
53 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$1K |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$312.76 |