| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
749 |
749 |
$73K |
| D1206 |
Topical application of fluoride varnish |
1,228 |
1,227 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,268 |
1,267 |
$49K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
333 |
216 |
$47K |
| D1120 |
Prophylaxis - child |
598 |
597 |
$44K |
| D2140 |
|
309 |
188 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,167 |
1,167 |
$33K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
274 |
166 |
$30K |
| D1351 |
Sealant - per tooth |
429 |
132 |
$24K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
156 |
107 |
$21K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
100 |
59 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,286 |
1,282 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
154 |
101 |
$17K |
| D0274 |
Bitewings - four radiographic images |
529 |
529 |
$16K |
| D0330 |
Panoramic radiographic image |
168 |
168 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
121 |
120 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
87 |
$5K |
| D3120 |
|
100 |
60 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
32 |
19 |
$3K |
| D0272 |
Bitewings - two radiographic images |
132 |
132 |
$3K |
| D2160 |
|
14 |
12 |
$2K |
| D2330 |
|
18 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
45 |
45 |
$794.62 |