| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
20,284 |
20,282 |
$907K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
7,153 |
2,218 |
$844K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
10,814 |
5,966 |
$726K |
| D1120 |
Prophylaxis - child |
22,616 |
22,588 |
$701K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
5,479 |
1,842 |
$544K |
| D0230 |
Intraoral - periapical each additional radiographic image |
127,759 |
24,733 |
$512K |
| D2140 |
|
7,087 |
4,697 |
$387K |
| D0274 |
Bitewings - four radiographic images |
9,367 |
9,364 |
$198K |
| D1208 |
Topical application of fluoride, excluding varnish |
22,716 |
22,683 |
$192K |
| D2160 |
|
1,773 |
1,342 |
$141K |
| D0272 |
Bitewings - two radiographic images |
10,220 |
10,211 |
$118K |
| D9248 |
|
3,334 |
3,332 |
$117K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,515 |
1,515 |
$95K |
| D0350 |
|
8,927 |
5,840 |
$90K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,307 |
791 |
$75K |
| D0220 |
Intraoral - periapical first radiographic image |
5,850 |
5,809 |
$69K |
| D2330 |
|
869 |
497 |
$67K |
| D1351 |
Sealant - per tooth |
2,791 |
970 |
$66K |
| D0145 |
Oral evaluation for a patient under three years of age |
332 |
332 |
$20K |
| D1310 |
|
311 |
311 |
$14K |
| D1510 |
|
30 |
27 |
$4K |
| D0603 |
|
193 |
193 |
$3K |
| D9993 |
|
12 |
12 |
$780.00 |