| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,905 |
1,901 |
$75K |
| D0140 |
Limited oral evaluation - problem focused |
851 |
844 |
$50K |
| D1206 |
Topical application of fluoride varnish |
2,086 |
2,082 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,522 |
1,522 |
$46K |
| D0272 |
Bitewings - two radiographic images |
898 |
898 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
353 |
351 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
743 |
728 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
712 |
387 |
$9K |
| D0240 |
|
402 |
266 |
$7K |
| D1110 |
Prophylaxis - adult |
149 |
149 |
$7K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
22 |
12 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
46 |
24 |
$4K |
| D0603 |
|
478 |
476 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
22 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
31 |
$2K |
| D2940 |
|
26 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
70 |
69 |
$2K |
| D0330 |
Panoramic radiographic image |
18 |
18 |
$1K |
| D0602 |
|
230 |
230 |
$1K |
| D9248 |
|
24 |
24 |
$1K |
| D0601 |
|
162 |
160 |
$957.00 |
| D1351 |
Sealant - per tooth |
36 |
13 |
$910.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
29 |
29 |
$756.00 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
64 |
62 |
$0.00 |