| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,197 |
2,197 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
2,640 |
2,640 |
$50K |
| D1206 |
Topical application of fluoride varnish |
2,788 |
2,788 |
$40K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
339 |
85 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
306 |
170 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
1,540 |
1,499 |
$21K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
825 |
752 |
$21K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
165 |
57 |
$13K |
| D1110 |
Prophylaxis - adult |
338 |
338 |
$13K |
| D0272 |
Bitewings - two radiographic images |
751 |
751 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,181 |
1,105 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
147 |
$4K |
| D0240 |
|
154 |
78 |
$2K |
| D0274 |
Bitewings - four radiographic images |
92 |
92 |
$2K |
| D1351 |
Sealant - per tooth |
67 |
27 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
15 |
$1K |