| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,865 |
898 |
$91K |
| D1120 |
Prophylaxis - child |
3,150 |
3,079 |
$90K |
| D7140 |
Extraction, erupted tooth or exposed root |
949 |
571 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
3,555 |
3,458 |
$49K |
| D1110 |
Prophylaxis - adult |
1,183 |
1,150 |
$42K |
| D0330 |
Panoramic radiographic image |
647 |
640 |
$41K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
749 |
740 |
$28K |
| D1206 |
Topical application of fluoride varnish |
4,321 |
4,214 |
$7K |
| D2140 |
|
233 |
167 |
$7K |
| D0272 |
Bitewings - two radiographic images |
3,187 |
3,093 |
$4K |
| D2160 |
|
18 |
14 |
$2K |
| D1330 |
|
4,228 |
4,119 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
14 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
88 |
84 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
1,310 |
1,219 |
$1K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
25 |
14 |
$1K |
| D9999 |
Unspecified adjunctive procedure, by report |
24 |
24 |
$600.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
518 |
397 |
$514.44 |
| D1351 |
Sealant - per tooth |
49 |
14 |
$0.00 |
| D9986 |
|
300 |
292 |
$0.00 |