| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,903 |
6,691 |
$123K |
| D1120 |
Prophylaxis - child |
5,821 |
5,651 |
$119K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,885 |
6,665 |
$99K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
841 |
238 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
993 |
446 |
$50K |
| D1110 |
Prophylaxis - adult |
970 |
941 |
$31K |
| D0272 |
Bitewings - two radiographic images |
2,850 |
2,765 |
$29K |
| D7140 |
Extraction, erupted tooth or exposed root |
412 |
210 |
$23K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
474 |
248 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
657 |
632 |
$16K |
| D1206 |
Topical application of fluoride varnish |
383 |
381 |
$11K |
| D0330 |
Panoramic radiographic image |
249 |
241 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
191 |
87 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
275 |
269 |
$6K |
| D2140 |
|
111 |
62 |
$4K |
| D1351 |
Sealant - per tooth |
118 |
37 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
41 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
476 |
457 |
$2K |