| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
9,638 |
9,598 |
$886K |
| D1351 |
Sealant - per tooth |
6,273 |
1,085 |
$232K |
| D0220 |
Intraoral - periapical first radiographic image |
5,783 |
5,652 |
$178K |
| D1120 |
Prophylaxis - child |
9,936 |
9,894 |
$174K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,481 |
1,005 |
$153K |
| D0272 |
Bitewings - two radiographic images |
5,113 |
5,083 |
$147K |
| D1206 |
Topical application of fluoride varnish |
10,627 |
10,582 |
$90K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
731 |
724 |
$82K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,420 |
714 |
$81K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
883 |
288 |
$70K |
| D0230 |
Intraoral - periapical each additional radiographic image |
9,591 |
4,250 |
$65K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,021 |
513 |
$57K |
| D0330 |
Panoramic radiographic image |
1,228 |
1,219 |
$45K |
| D0274 |
Bitewings - four radiographic images |
2,304 |
2,293 |
$44K |
| D1110 |
Prophylaxis - adult |
528 |
524 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
493 |
480 |
$20K |
| D2140 |
|
850 |
391 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
449 |
163 |
$15K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,441 |
596 |
$13K |
| D9420 |
|
25 |
25 |
$11K |
| D2330 |
|
24 |
13 |
$3K |
| D9248 |
|
28 |
28 |
$3K |
| D2332 |
|
25 |
13 |
$2K |