| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
14,680 |
14,589 |
$1.48M |
| D1351 |
Sealant - per tooth |
12,898 |
3,024 |
$448K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
5,301 |
1,339 |
$347K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,713 |
2,690 |
$304K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
4,038 |
1,739 |
$247K |
| D1120 |
Prophylaxis - child |
16,007 |
15,884 |
$241K |
| D0220 |
Intraoral - periapical first radiographic image |
10,629 |
10,469 |
$205K |
| D0272 |
Bitewings - two radiographic images |
8,780 |
8,693 |
$167K |
| D2140 |
|
3,309 |
1,642 |
$163K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,762 |
1,413 |
$157K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,994 |
879 |
$156K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,727 |
799 |
$146K |
| D1206 |
Topical application of fluoride varnish |
16,300 |
16,180 |
$108K |
| D0330 |
Panoramic radiographic image |
3,280 |
3,255 |
$83K |
| D0230 |
Intraoral - periapical each additional radiographic image |
14,629 |
8,377 |
$67K |
| D0274 |
Bitewings - four radiographic images |
4,807 |
4,778 |
$57K |
| D9248 |
|
691 |
679 |
$46K |
| D9420 |
|
559 |
548 |
$27K |
| D1110 |
Prophylaxis - adult |
1,377 |
1,364 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
485 |
476 |
$21K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
313 |
137 |
$15K |
| D4355 |
|
48 |
48 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
544 |
538 |
$1K |