| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,947 |
6,903 |
$685K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,211 |
1,015 |
$146K |
| D0220 |
Intraoral - periapical first radiographic image |
4,796 |
4,741 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
687 |
683 |
$71K |
| D2140 |
|
484 |
298 |
$52K |
| D1351 |
Sealant - per tooth |
875 |
282 |
$50K |
| D1120 |
Prophylaxis - child |
7,194 |
7,138 |
$44K |
| D0272 |
Bitewings - two radiographic images |
4,850 |
4,798 |
$43K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,195 |
505 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
829 |
500 |
$19K |
| D1206 |
Topical application of fluoride varnish |
6,131 |
6,116 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,471 |
4,404 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
66 |
65 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
350 |
335 |
$934.80 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,050 |
442 |
$651.99 |
| D0330 |
Panoramic radiographic image |
504 |
504 |
$465.98 |
| D2330 |
|
14 |
12 |
$54.33 |
| D0274 |
Bitewings - four radiographic images |
26 |
26 |
$0.00 |