| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,492 |
1,472 |
$89K |
| D1120 |
Prophylaxis - child |
1,500 |
1,472 |
$38K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
278 |
63 |
$37K |
| D1351 |
Sealant - per tooth |
748 |
103 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,824 |
1,803 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
108 |
56 |
$12K |
| D0272 |
Bitewings - two radiographic images |
505 |
496 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
25 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
57 |
34 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
131 |
54 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
40 |
$3K |
| D2140 |
|
25 |
13 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
24 |
13 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
37 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
124 |
116 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$553.11 |
| D0274 |
Bitewings - four radiographic images |
40 |
37 |
$471.36 |
| D9420 |
|
52 |
52 |
$445.03 |