| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,976 |
5,914 |
$117K |
| D1351 |
Sealant - per tooth |
6,157 |
1,750 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
4,963 |
4,913 |
$95K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,854 |
5,803 |
$85K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,692 |
1,058 |
$71K |
| D0220 |
Intraoral - periapical first radiographic image |
6,440 |
6,260 |
$50K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
505 |
320 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
897 |
520 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,191 |
1,182 |
$30K |
| D0272 |
Bitewings - two radiographic images |
3,738 |
3,708 |
$30K |
| D2140 |
|
897 |
661 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,325 |
5,587 |
$26K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
245 |
157 |
$17K |
| D0274 |
Bitewings - four radiographic images |
916 |
898 |
$10K |
| D2332 |
|
162 |
92 |
$9K |
| D0350 |
|
1,865 |
1,810 |
$9K |
| D1999 |
|
114 |
114 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
166 |
166 |
$7K |
| D1206 |
Topical application of fluoride varnish |
280 |
270 |
$5K |
| D1110 |
Prophylaxis - adult |
171 |
171 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
222 |
219 |
$4K |
| D2160 |
|
16 |
15 |
$720.00 |
| D9430 |
|
55 |
51 |
$612.00 |
| D0602 |
|
749 |
740 |
$0.00 |
| D1310 |
|
2,334 |
2,314 |
$0.00 |
| D0603 |
|
1,284 |
1,271 |
$0.00 |
| D0601 |
|
110 |
110 |
$0.00 |
| D9993 |
|
2,334 |
2,315 |
$0.00 |
| D9986 |
|
301 |
287 |
$0.00 |
| D9987 |
|
56 |
53 |
$0.00 |