| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,407 |
6,391 |
$344K |
| D1120 |
Prophylaxis - child |
8,082 |
8,062 |
$300K |
| D0230 |
Intraoral - periapical each additional radiographic image |
37,829 |
8,413 |
$150K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,086 |
8,067 |
$84K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,880 |
1,452 |
$74K |
| D0272 |
Bitewings - two radiographic images |
5,886 |
5,868 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
875 |
875 |
$52K |
| D1351 |
Sealant - per tooth |
1,895 |
524 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
791 |
509 |
$45K |
| D0220 |
Intraoral - periapical first radiographic image |
3,331 |
3,225 |
$39K |
| D0145 |
Oral evaluation for a patient under three years of age |
550 |
549 |
$28K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
177 |
122 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
37 |
26 |
$4K |
| D2140 |
|
52 |
44 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
16 |
12 |
$2K |
| D9430 |
|
12 |
12 |
$384.00 |