| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
806 |
415 |
$55K |
| D1120 |
Prophylaxis - child |
1,280 |
1,156 |
$52K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,282 |
1,158 |
$33K |
| D0120 |
Periodic oral evaluation - established patient |
993 |
900 |
$27K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
626 |
576 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
215 |
177 |
$12K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
144 |
115 |
$10K |
| D0274 |
Bitewings - four radiographic images |
502 |
473 |
$8K |
| D0272 |
Bitewings - two radiographic images |
699 |
622 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,083 |
984 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
48 |
43 |
$5K |
| D2140 |
|
124 |
100 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
891 |
787 |
$4K |
| D9110 |
|
52 |
43 |
$3K |
| D1110 |
Prophylaxis - adult |
53 |
53 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
14 |
13 |
$843.20 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$226.80 |