| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,037 |
898 |
$42K |
| D1206 |
Topical application of fluoride varnish |
1,034 |
888 |
$38K |
| D4341 |
|
481 |
97 |
$29K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
516 |
289 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
992 |
849 |
$24K |
| D0274 |
Bitewings - four radiographic images |
971 |
822 |
$16K |
| D3110 |
|
858 |
396 |
$13K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
1,092 |
752 |
$12K |
| D2140 |
|
264 |
185 |
$12K |
| D1351 |
Sealant - per tooth |
807 |
223 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,104 |
1,007 |
$10K |
| D2160 |
|
122 |
75 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
132 |
77 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
193 |
89 |
$6K |
| D9215 |
|
1,416 |
589 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
462 |
375 |
$5K |
| D0330 |
Panoramic radiographic image |
170 |
145 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
107 |
62 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
55 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
33 |
12 |
$122.88 |
| D0120 |
Periodic oral evaluation - established patient |
31 |
16 |
$0.00 |