| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
4,692 |
4,691 |
$242K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
3,159 |
2,111 |
$227K |
| D0120 |
Periodic oral evaluation - established patient |
7,995 |
7,990 |
$209K |
| D2160 |
|
1,529 |
1,240 |
$138K |
| D1120 |
Prophylaxis - child |
3,284 |
3,280 |
$128K |
| D0274 |
Bitewings - four radiographic images |
4,749 |
4,747 |
$124K |
| D2161 |
|
1,021 |
868 |
$117K |
| D0220 |
Intraoral - periapical first radiographic image |
8,224 |
8,206 |
$104K |
| D1351 |
Sealant - per tooth |
2,669 |
763 |
$100K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,224 |
902 |
$85K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,224 |
5,220 |
$66K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,850 |
7,846 |
$50K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
695 |
571 |
$49K |
| D0272 |
Bitewings - two radiographic images |
2,969 |
2,967 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
869 |
610 |
$45K |
| D2140 |
|
780 |
579 |
$36K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
549 |
385 |
$26K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
115 |
99 |
$10K |
| D2335 |
|
69 |
53 |
$9K |
| D2331 |
|
71 |
46 |
$5K |
| D1206 |
Topical application of fluoride varnish |
130 |
130 |
$4K |
| D2330 |
|
49 |
43 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
119 |
119 |
$1K |
| D0603 |
|
454 |
454 |
$454.00 |
| D0601 |
|
354 |
354 |
$354.00 |
| D0602 |
|
189 |
189 |
$189.00 |