| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,598 |
1,595 |
$80K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
660 |
204 |
$79K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,084 |
468 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
993 |
993 |
$66K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
657 |
202 |
$65K |
| D2140 |
|
860 |
447 |
$47K |
| D1351 |
Sealant - per tooth |
1,140 |
400 |
$43K |
| D1310 |
|
943 |
939 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,635 |
1,632 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
8,298 |
1,587 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
526 |
271 |
$30K |
| D0145 |
Oral evaluation for a patient under three years of age |
298 |
298 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
353 |
352 |
$18K |
| D2160 |
|
174 |
108 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,152 |
1,133 |
$14K |
| D0350 |
|
1,240 |
544 |
$12K |
| D0603 |
|
690 |
687 |
$10K |
| D0272 |
Bitewings - two radiographic images |
525 |
525 |
$6K |
| D2331 |
|
28 |
17 |
$2K |
| D2330 |
|
17 |
13 |
$1K |
| D0602 |
|
38 |
38 |
$555.00 |
| D0601 |
|
22 |
22 |
$315.00 |