| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,540 |
5,532 |
$169K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,071 |
400 |
$121K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,787 |
865 |
$117K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,270 |
3,264 |
$113K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,652 |
5,644 |
$101K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,019 |
388 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
2,471 |
2,471 |
$55K |
| D0274 |
Bitewings - four radiographic images |
1,518 |
1,515 |
$44K |
| D2140 |
|
791 |
568 |
$43K |
| D0220 |
Intraoral - periapical first radiographic image |
3,509 |
3,499 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,467 |
3,456 |
$31K |
| D0272 |
Bitewings - two radiographic images |
1,487 |
1,485 |
$30K |
| D1351 |
Sealant - per tooth |
1,012 |
264 |
$24K |
| D0330 |
Panoramic radiographic image |
192 |
192 |
$10K |
| D1110 |
Prophylaxis - adult |
254 |
254 |
$9K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
81 |
79 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
21 |
16 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$414.59 |