| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,595 |
1,594 |
$62K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
717 |
524 |
$59K |
| D2140 |
|
815 |
616 |
$55K |
| D0120 |
Periodic oral evaluation - established patient |
1,989 |
1,988 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,933 |
1,932 |
$45K |
| D1110 |
Prophylaxis - adult |
669 |
669 |
$35K |
| D0274 |
Bitewings - four radiographic images |
853 |
852 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,509 |
1,496 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,599 |
1,315 |
$23K |
| D0272 |
Bitewings - two radiographic images |
399 |
399 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
201 |
201 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
68 |
50 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
18 |
16 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
16 |
$2K |
| D0191 |
|
35 |
35 |
$525.00 |