| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,486 |
4,435 |
$216K |
| D1351 |
Sealant - per tooth |
5,265 |
815 |
$149K |
| D1120 |
Prophylaxis - child |
4,606 |
4,560 |
$133K |
| D1206 |
Topical application of fluoride varnish |
4,348 |
4,292 |
$74K |
| D0272 |
Bitewings - two radiographic images |
2,947 |
2,916 |
$58K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
676 |
322 |
$48K |
| D0274 |
Bitewings - four radiographic images |
1,381 |
1,376 |
$39K |
| D7140 |
Extraction, erupted tooth or exposed root |
493 |
259 |
$38K |
| D0330 |
Panoramic radiographic image |
944 |
940 |
$37K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
340 |
113 |
$35K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
503 |
503 |
$34K |
| D0220 |
Intraoral - periapical first radiographic image |
3,090 |
3,049 |
$32K |
| D2140 |
|
468 |
276 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,467 |
2,379 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
167 |
82 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
353 |
339 |
$12K |
| D1110 |
Prophylaxis - adult |
290 |
286 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
135 |
90 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
176 |
176 |
$3K |
| D2332 |
|
23 |
13 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
23 |
12 |
$881.36 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
92 |
91 |
$324.43 |
| D0240 |
|
15 |
15 |
$209.00 |