| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,615 |
4,549 |
$154K |
| D1206 |
Topical application of fluoride varnish |
5,731 |
5,616 |
$118K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,676 |
1,044 |
$113K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,396 |
1,004 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
4,870 |
4,783 |
$98K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,842 |
2,814 |
$88K |
| D0272 |
Bitewings - two radiographic images |
3,431 |
3,381 |
$68K |
| D1110 |
Prophylaxis - adult |
1,319 |
1,293 |
$62K |
| D1351 |
Sealant - per tooth |
1,725 |
468 |
$56K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
626 |
507 |
$52K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
258 |
218 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
385 |
281 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
395 |
321 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,359 |
1,359 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
982 |
959 |
$24K |
| D0210 |
Intraoral - complete series of radiographic images |
466 |
431 |
$22K |
| D9630 |
|
616 |
565 |
$12K |
| D9920 |
|
155 |
151 |
$10K |
| D3120 |
|
191 |
155 |
$3K |
| D1354 |
|
252 |
66 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
277 |
265 |
$3K |
| D0240 |
|
206 |
191 |
$2K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$2K |
| D0274 |
Bitewings - four radiographic images |
21 |
12 |
$579.60 |