| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,968 |
2,963 |
$147K |
| D0120 |
Periodic oral evaluation - established patient |
3,614 |
3,605 |
$99K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,077 |
687 |
$98K |
| D1206 |
Topical application of fluoride varnish |
3,454 |
3,445 |
$88K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
739 |
555 |
$60K |
| D1110 |
Prophylaxis - adult |
997 |
994 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
499 |
368 |
$49K |
| D0272 |
Bitewings - two radiographic images |
1,543 |
1,537 |
$45K |
| D7140 |
Extraction, erupted tooth or exposed root |
441 |
352 |
$42K |
| D1351 |
Sealant - per tooth |
1,033 |
396 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
405 |
404 |
$22K |
| D0274 |
Bitewings - four radiographic images |
576 |
574 |
$22K |
| D0330 |
Panoramic radiographic image |
178 |
178 |
$15K |
| D2140 |
|
151 |
112 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
316 |
311 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
20 |
14 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
63 |
63 |
$3K |
| D2331 |
|
14 |
13 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
19 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$464.39 |