| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,504 |
13,501 |
$469K |
| D0120 |
Periodic oral evaluation - established patient |
19,800 |
19,797 |
$466K |
| D1110 |
Prophylaxis - adult |
6,655 |
6,655 |
$315K |
| D0220 |
Intraoral - periapical first radiographic image |
19,265 |
19,213 |
$219K |
| D0230 |
Intraoral - periapical each additional radiographic image |
18,148 |
18,119 |
$218K |
| D1206 |
Topical application of fluoride varnish |
7,125 |
7,122 |
$169K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,818 |
12,815 |
$151K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
907 |
815 |
$122K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
912 |
818 |
$105K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,066 |
978 |
$90K |
| D1351 |
Sealant - per tooth |
945 |
681 |
$86K |
| D7140 |
Extraction, erupted tooth or exposed root |
925 |
876 |
$47K |
| D2140 |
|
111 |
107 |
$6K |
| D0272 |
Bitewings - two radiographic images |
337 |
337 |
$4K |
| D2160 |
|
33 |
29 |
$3K |
| D2933 |
|
16 |
14 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
106 |
106 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
39 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
18 |
$2K |