| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
20,123 |
20,118 |
$706K |
| D0120 |
Periodic oral evaluation - established patient |
29,323 |
29,318 |
$694K |
| D1351 |
Sealant - per tooth |
15,934 |
4,687 |
$685K |
| D1110 |
Prophylaxis - adult |
9,148 |
9,146 |
$409K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
5,742 |
3,926 |
$396K |
| D1208 |
Topical application of fluoride, excluding varnish |
29,323 |
29,315 |
$353K |
| D0220 |
Intraoral - periapical first radiographic image |
29,428 |
29,269 |
$332K |
| D0272 |
Bitewings - two radiographic images |
20,407 |
20,405 |
$275K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,993 |
3,741 |
$220K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,316 |
23,286 |
$205K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,150 |
1,687 |
$194K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,847 |
2,332 |
$157K |
| D2335 |
|
400 |
256 |
$45K |
| D0140 |
Limited oral evaluation - problem focused |
2,641 |
2,625 |
$32K |
| D2140 |
|
564 |
484 |
$23K |
| D2160 |
|
313 |
274 |
$22K |
| D2332 |
|
104 |
89 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
82 |
58 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
26 |
$2K |
| D1999 |
|
13 |
13 |
$650.00 |
| D0210 |
Intraoral - complete series of radiographic images |
47 |
47 |
$558.18 |