| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,697 |
3,305 |
$89K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,748 |
2,298 |
$68K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,671 |
2,539 |
$53K |
| D1110 |
Prophylaxis - adult |
1,205 |
1,160 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
2,032 |
1,979 |
$48K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
593 |
309 |
$31K |
| D0330 |
Panoramic radiographic image |
821 |
708 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,049 |
939 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,616 |
1,416 |
$22K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
524 |
465 |
$15K |
| D0272 |
Bitewings - two radiographic images |
897 |
836 |
$14K |
| D2140 |
|
281 |
181 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
41 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
213 |
189 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
89 |
52 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
673 |
585 |
$6K |
| D2160 |
|
48 |
31 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
30 |
14 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
30 |
14 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
35 |
24 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
52 |
28 |
$411.02 |