| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
10,486 |
10,301 |
$833K |
| D1351 |
Sealant - per tooth |
9,665 |
2,214 |
$345K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,070 |
807 |
$148K |
| D1120 |
Prophylaxis - child |
10,231 |
10,062 |
$141K |
| D0272 |
Bitewings - two radiographic images |
6,345 |
6,235 |
$138K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,431 |
773 |
$118K |
| D0220 |
Intraoral - periapical first radiographic image |
2,394 |
2,348 |
$102K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,870 |
981 |
$81K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,078 |
667 |
$77K |
| D1206 |
Topical application of fluoride varnish |
11,523 |
11,337 |
$72K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,080 |
1,063 |
$68K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,391 |
797 |
$54K |
| D0140 |
Limited oral evaluation - problem focused |
726 |
709 |
$36K |
| D0274 |
Bitewings - four radiographic images |
1,038 |
1,028 |
$30K |
| D1110 |
Prophylaxis - adult |
1,059 |
1,040 |
$26K |
| D2140 |
|
776 |
498 |
$25K |
| D0330 |
Panoramic radiographic image |
1,364 |
1,345 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,376 |
1,222 |
$9K |
| D1354 |
|
1,078 |
463 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
242 |
96 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
35 |
24 |
$4K |
| D2330 |
|
38 |
24 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$184.10 |