| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,182 |
4,173 |
$212K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,184 |
910 |
$147K |
| D1310 |
|
2,932 |
2,930 |
$129K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,793 |
1,792 |
$120K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
986 |
322 |
$118K |
| D2140 |
|
1,889 |
874 |
$103K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,237 |
4,228 |
$100K |
| D0120 |
Periodic oral evaluation - established patient |
1,529 |
1,528 |
$98K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
978 |
320 |
$97K |
| D0230 |
Intraoral - periapical each additional radiographic image |
20,944 |
4,280 |
$87K |
| D1351 |
Sealant - per tooth |
1,517 |
591 |
$58K |
| D0145 |
Oral evaluation for a patient under three years of age |
759 |
759 |
$51K |
| D7140 |
Extraction, erupted tooth or exposed root |
793 |
399 |
$46K |
| D0220 |
Intraoral - periapical first radiographic image |
3,441 |
3,401 |
$41K |
| D0603 |
|
2,495 |
2,493 |
$36K |
| D0350 |
|
2,736 |
1,144 |
$28K |
| D2160 |
|
289 |
179 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,001 |
1,001 |
$12K |
| D2330 |
|
87 |
60 |
$7K |
| D2331 |
|
61 |
40 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
12 |
$1K |
| D0601 |
|
83 |
83 |
$1K |