| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,327 |
5,992 |
$254K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,159 |
5,825 |
$156K |
| D0120 |
Periodic oral evaluation - established patient |
5,724 |
5,410 |
$153K |
| D1351 |
Sealant - per tooth |
2,293 |
1,066 |
$142K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
843 |
601 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,255 |
2,120 |
$46K |
| D0274 |
Bitewings - four radiographic images |
2,481 |
2,335 |
$40K |
| D9110 |
|
709 |
672 |
$37K |
| D7140 |
Extraction, erupted tooth or exposed root |
776 |
598 |
$36K |
| D2140 |
|
763 |
597 |
$30K |
| D0272 |
Bitewings - two radiographic images |
3,056 |
2,869 |
$28K |
| D1110 |
Prophylaxis - adult |
730 |
686 |
$23K |
| D0220 |
Intraoral - periapical first radiographic image |
3,871 |
3,606 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,451 |
2,209 |
$12K |
| D4341 |
|
43 |
29 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
87 |
62 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
289 |
263 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
95 |
$4K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
45 |
40 |
$4K |
| D1206 |
Topical application of fluoride varnish |
35 |
35 |
$884.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
13 |
$843.20 |
| D2330 |
|
15 |
12 |
$519.00 |
| D9310 |
|
30 |
30 |
$495.90 |