| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,665 |
6,609 |
$697K |
| D1351 |
Sealant - per tooth |
3,867 |
792 |
$171K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
3,019 |
1,221 |
$128K |
| D0220 |
Intraoral - periapical first radiographic image |
3,101 |
3,042 |
$112K |
| D0272 |
Bitewings - two radiographic images |
4,458 |
4,393 |
$109K |
| D2140 |
|
2,440 |
1,154 |
$107K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,256 |
381 |
$73K |
| D1120 |
Prophylaxis - child |
6,896 |
6,841 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
543 |
537 |
$62K |
| D0140 |
Limited oral evaluation - problem focused |
434 |
417 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,068 |
572 |
$21K |
| D1206 |
Topical application of fluoride varnish |
7,033 |
6,980 |
$16K |
| D2330 |
|
128 |
80 |
$15K |
| D2332 |
|
116 |
63 |
$14K |
| D9248 |
|
208 |
204 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,917 |
2,033 |
$8K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
871 |
283 |
$7K |
| D9420 |
|
118 |
118 |
$2K |
| D0274 |
Bitewings - four radiographic images |
1,505 |
1,502 |
$2K |
| D0330 |
Panoramic radiographic image |
850 |
849 |
$1K |
| D2160 |
|
32 |
24 |
$757.44 |
| D1110 |
Prophylaxis - adult |
259 |
255 |
$0.00 |