| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,739 |
2,739 |
$92K |
| D0120 |
Periodic oral evaluation - established patient |
2,707 |
2,706 |
$68K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
755 |
438 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,351 |
1,351 |
$35K |
| D1206 |
Topical application of fluoride varnish |
1,598 |
1,597 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,522 |
1,501 |
$24K |
| D0272 |
Bitewings - two radiographic images |
960 |
960 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
273 |
163 |
$21K |
| D2140 |
|
291 |
187 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,550 |
889 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
94 |
40 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
293 |
292 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
101 |
66 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
278 |
278 |
$11K |
| D9110 |
|
118 |
117 |
$9K |
| D9420 |
|
13 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$984.00 |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$47.47 |