| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,037 |
1,933 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
2,047 |
1,935 |
$56K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,260 |
1,209 |
$33K |
| D1351 |
Sealant - per tooth |
304 |
188 |
$18K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
226 |
198 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
155 |
116 |
$10K |
| D0272 |
Bitewings - two radiographic images |
730 |
689 |
$7K |
| D2140 |
|
156 |
143 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
53 |
41 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
110 |
97 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
839 |
781 |
$5K |
| D0274 |
Bitewings - four radiographic images |
203 |
197 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
52 |
40 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
119 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
546 |
514 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
41 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$774.83 |
| D1110 |
Prophylaxis - adult |
14 |
14 |
$677.32 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
26 |
$405.00 |