| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2750 |
|
1,927 |
1,692 |
$301K |
| D0120 |
Periodic oral evaluation - established patient |
21,250 |
21,009 |
$234K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
9,655 |
6,541 |
$226K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
3,807 |
2,609 |
$177K |
| D1120 |
Prophylaxis - child |
10,328 |
10,231 |
$168K |
| D1110 |
Prophylaxis - adult |
7,551 |
7,454 |
$113K |
| D1208 |
Topical application of fluoride, excluding varnish |
13,510 |
13,324 |
$93K |
| D2140 |
|
4,578 |
3,466 |
$89K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,586 |
2,417 |
$78K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
3,250 |
2,268 |
$76K |
| D0274 |
Bitewings - four radiographic images |
9,913 |
9,758 |
$57K |
| D0140 |
Limited oral evaluation - problem focused |
3,705 |
3,551 |
$49K |
| D0220 |
Intraoral - periapical first radiographic image |
18,860 |
18,460 |
$46K |
| D1351 |
Sealant - per tooth |
4,923 |
1,498 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,415 |
17,115 |
$34K |
| D2954 |
|
1,268 |
1,142 |
$30K |
| D0272 |
Bitewings - two radiographic images |
5,825 |
5,788 |
$25K |
| D2160 |
|
1,022 |
873 |
$25K |
| D3330 |
Endodontic therapy, molar tooth (excluding final restoration) |
30 |
27 |
$9K |
| D2331 |
|
185 |
142 |
$5K |
| D2950 |
|
377 |
350 |
$4K |
| D4355 |
|
54 |
54 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
133 |
133 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
100 |
77 |
$1K |
| D2332 |
|
21 |
12 |
$584.00 |
| D2330 |
|
21 |
13 |
$382.50 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
13 |
$220.00 |
| D2920 |
|
12 |
12 |
$25.80 |
| D1999 |
|
1,498 |
1,344 |
$0.00 |