| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
12,902 |
12,902 |
$581K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
4,080 |
1,237 |
$481K |
| D1120 |
Prophylaxis - child |
14,460 |
14,441 |
$448K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
6,214 |
3,252 |
$417K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,307 |
1,068 |
$328K |
| D0230 |
Intraoral - periapical each additional radiographic image |
78,383 |
15,375 |
$317K |
| D2140 |
|
4,025 |
2,598 |
$219K |
| D0274 |
Bitewings - four radiographic images |
6,180 |
6,177 |
$131K |
| D1208 |
Topical application of fluoride, excluding varnish |
13,701 |
13,674 |
$109K |
| D2160 |
|
1,338 |
846 |
$107K |
| D9248 |
|
2,027 |
2,022 |
$71K |
| D0272 |
Bitewings - two radiographic images |
5,807 |
5,804 |
$67K |
| D1351 |
Sealant - per tooth |
2,858 |
1,091 |
$66K |
| D2330 |
|
810 |
445 |
$62K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,016 |
600 |
$58K |
| D0350 |
|
5,253 |
3,396 |
$56K |
| D0220 |
Intraoral - periapical first radiographic image |
3,204 |
3,167 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
462 |
462 |
$29K |
| D1206 |
Topical application of fluoride varnish |
799 |
799 |
$14K |
| D1310 |
|
164 |
164 |
$7K |
| D0603 |
|
72 |
72 |
$1K |
| D9993 |
|
15 |
15 |
$975.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$826.00 |