| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,689 |
2,670 |
$79K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,263 |
718 |
$75K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
733 |
330 |
$74K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,298 |
3,278 |
$59K |
| D0120 |
Periodic oral evaluation - established patient |
2,940 |
2,920 |
$58K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
687 |
301 |
$52K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
787 |
747 |
$34K |
| D1110 |
Prophylaxis - adult |
714 |
713 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
507 |
381 |
$25K |
| D0272 |
Bitewings - two radiographic images |
1,514 |
1,505 |
$24K |
| D0330 |
Panoramic radiographic image |
617 |
613 |
$23K |
| D7140 |
Extraction, erupted tooth or exposed root |
294 |
181 |
$19K |
| D1310 |
|
1,293 |
1,288 |
$14K |
| D1330 |
|
1,262 |
1,257 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
573 |
569 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
44 |
37 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
183 |
182 |
$1K |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$234.00 |