| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,768 |
4,701 |
$538K |
| D1351 |
Sealant - per tooth |
4,656 |
934 |
$128K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,523 |
724 |
$77K |
| D0220 |
Intraoral - periapical first radiographic image |
3,510 |
3,412 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
423 |
410 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
451 |
213 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
287 |
152 |
$21K |
| D1120 |
Prophylaxis - child |
4,976 |
4,901 |
$20K |
| D2140 |
|
322 |
209 |
$16K |
| D0272 |
Bitewings - two radiographic images |
2,072 |
2,030 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
230 |
71 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
46 |
18 |
$5K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
682 |
574 |
$5K |
| D1206 |
Topical application of fluoride varnish |
5,148 |
5,066 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,097 |
3,030 |
$4K |
| D2160 |
|
52 |
27 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
118 |
112 |
$3K |
| D0330 |
Panoramic radiographic image |
672 |
655 |
$2K |
| D0274 |
Bitewings - four radiographic images |
840 |
823 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$1K |
| D1110 |
Prophylaxis - adult |
54 |
54 |
$152.40 |
| D9248 |
|
40 |
38 |
$135.00 |