| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,274 |
1,249 |
$51K |
| D1351 |
Sealant - per tooth |
876 |
290 |
$37K |
| D0120 |
Periodic oral evaluation - established patient |
1,103 |
1,086 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
839 |
824 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
427 |
263 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
160 |
80 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
209 |
127 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
451 |
443 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
146 |
77 |
$9K |
| D0274 |
Bitewings - four radiographic images |
479 |
477 |
$8K |
| D1206 |
Topical application of fluoride varnish |
306 |
304 |
$8K |
| D9110 |
|
80 |
80 |
$4K |
| D0272 |
Bitewings - two radiographic images |
461 |
455 |
$4K |
| D1110 |
Prophylaxis - adult |
162 |
159 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
724 |
701 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
506 |
484 |
$3K |
| D2140 |
|
53 |
40 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
44 |
42 |
$648.00 |