| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
673 |
671 |
$20K |
| D0350 |
|
2,100 |
622 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,112 |
630 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
367 |
366 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
128 |
82 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
645 |
643 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
207 |
192 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
66 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
53 |
15 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
160 |
160 |
$5K |
| D1351 |
Sealant - per tooth |
253 |
85 |
$5K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
81 |
42 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
51 |
14 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
88 |
58 |
$5K |
| D0272 |
Bitewings - two radiographic images |
463 |
461 |
$5K |
| D2140 |
|
22 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$250.00 |
| D9910 |
|
77 |
72 |
$189.20 |