| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,225 |
5,225 |
$214K |
| D0120 |
Periodic oral evaluation - established patient |
7,194 |
7,194 |
$198K |
| D1110 |
Prophylaxis - adult |
1,972 |
1,972 |
$109K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,534 |
6,522 |
$94K |
| D0220 |
Intraoral - periapical first radiographic image |
6,841 |
6,809 |
$91K |
| D1351 |
Sealant - per tooth |
1,834 |
511 |
$75K |
| D1206 |
Topical application of fluoride varnish |
2,469 |
2,469 |
$70K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,666 |
4,666 |
$62K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
721 |
515 |
$57K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
477 |
304 |
$52K |
| D7140 |
Extraction, erupted tooth or exposed root |
880 |
555 |
$50K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
463 |
247 |
$38K |
| D2140 |
|
107 |
83 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$888.25 |