| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,064 |
2,034 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
1,046 |
1,025 |
$78K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
740 |
740 |
$49K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,010 |
1,899 |
$26K |
| D1310 |
|
481 |
469 |
$22K |
| D1351 |
Sealant - per tooth |
952 |
223 |
$22K |
| D0272 |
Bitewings - two radiographic images |
1,635 |
1,618 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,432 |
1,416 |
$17K |
| D1206 |
Topical application of fluoride varnish |
539 |
528 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
132 |
63 |
$13K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
187 |
101 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
99 |
39 |
$12K |
| D9993 |
|
180 |
179 |
$9K |
| D0350 |
|
861 |
385 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
134 |
89 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
215 |
215 |
$7K |
| D0603 |
|
411 |
399 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
39 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
30 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
192 |
188 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
57 |
50 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
47 |
47 |
$2K |
| D2140 |
|
23 |
13 |
$1K |
| D9430 |
|
28 |
26 |
$896.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
13 |
13 |
$767.00 |