| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,471 |
2,427 |
$155K |
| D0120 |
Periodic oral evaluation - established patient |
2,500 |
2,478 |
$134K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,231 |
3,178 |
$116K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
306 |
90 |
$63K |
| D1110 |
Prophylaxis - adult |
689 |
682 |
$54K |
| D0272 |
Bitewings - two radiographic images |
1,255 |
1,228 |
$49K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
283 |
131 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
52 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
269 |
262 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
394 |
373 |
$10K |
| D9420 |
|
41 |
38 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
54 |
25 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
93 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
26 |
$7K |
| D2140 |
|
59 |
27 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
243 |
193 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
15 |
$3K |
| D1999 |
|
228 |
223 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
14 |
13 |
$1K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$799.20 |