| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,257 |
3,224 |
$374K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,022 |
651 |
$148K |
| D1351 |
Sealant - per tooth |
861 |
331 |
$47K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
317 |
315 |
$40K |
| D0220 |
Intraoral - periapical first radiographic image |
3,867 |
3,810 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
365 |
123 |
$33K |
| D9248 |
|
637 |
631 |
$28K |
| D1120 |
Prophylaxis - child |
3,444 |
3,406 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
533 |
244 |
$18K |
| D0272 |
Bitewings - two radiographic images |
2,450 |
2,405 |
$18K |
| D1206 |
Topical application of fluoride varnish |
3,510 |
3,472 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
165 |
64 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,860 |
3,582 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
223 |
88 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$3K |
| D0330 |
Panoramic radiographic image |
214 |
213 |
$1K |
| D2140 |
|
59 |
29 |
$708.62 |
| D0274 |
Bitewings - four radiographic images |
37 |
37 |
$398.86 |