| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,379 |
1,332 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,128 |
1,096 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,443 |
1,401 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,343 |
1,314 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,601 |
1,146 |
$10K |
| D0272 |
Bitewings - two radiographic images |
722 |
708 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
86 |
38 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
59 |
59 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
69 |
68 |
$793.59 |
| D7140 |
Extraction, erupted tooth or exposed root |
73 |
39 |
$689.67 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
62 |
28 |
$632.48 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
64 |
35 |
$517.98 |
| D2140 |
|
25 |
15 |
$375.96 |
| D0140 |
Limited oral evaluation - problem focused |
45 |
44 |
$339.83 |
| D1351 |
Sealant - per tooth |
82 |
24 |
$337.74 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
74 |
71 |
$164.23 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$97.48 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$0.00 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$0.00 |