| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
6,098 |
2,800 |
$398K |
| D1120 |
Prophylaxis - child |
7,121 |
6,967 |
$294K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,613 |
1,154 |
$229K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,076 |
6,920 |
$185K |
| D0120 |
Periodic oral evaluation - established patient |
6,416 |
6,271 |
$181K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,427 |
1,087 |
$106K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,206 |
911 |
$90K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,978 |
1,939 |
$48K |
| D2140 |
|
958 |
743 |
$44K |
| D0274 |
Bitewings - four radiographic images |
2,372 |
2,298 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
6,602 |
6,419 |
$42K |
| D0272 |
Bitewings - two radiographic images |
3,193 |
3,107 |
$34K |
| D4341 |
|
172 |
109 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,064 |
5,745 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
337 |
293 |
$20K |
| D2160 |
|
222 |
165 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
147 |
146 |
$3K |
| D9110 |
|
39 |
39 |
$2K |
| D1110 |
Prophylaxis - adult |
35 |
34 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
15 |
12 |
$338.70 |