| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,413 |
1,404 |
$38K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
532 |
243 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,077 |
1,075 |
$31K |
| D2140 |
|
564 |
250 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,900 |
1,435 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,357 |
1,340 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,458 |
1,447 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
268 |
267 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
223 |
130 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
138 |
67 |
$9K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
89 |
37 |
$9K |
| D1351 |
Sealant - per tooth |
303 |
111 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
59 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
52 |
21 |
$5K |
| D0350 |
|
498 |
417 |
$4K |
| D0272 |
Bitewings - two radiographic images |
146 |
146 |
$2K |