| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
6,591 |
2,487 |
$90K |
| D1120 |
Prophylaxis - child |
1,937 |
1,937 |
$85K |
| D0120 |
Periodic oral evaluation - established patient |
2,312 |
2,312 |
$81K |
| D7140 |
Extraction, erupted tooth or exposed root |
876 |
527 |
$80K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,437 |
2,437 |
$67K |
| D0220 |
Intraoral - periapical first radiographic image |
2,723 |
2,682 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
297 |
196 |
$38K |
| D0140 |
Limited oral evaluation - problem focused |
541 |
522 |
$33K |
| D1351 |
Sealant - per tooth |
982 |
220 |
$32K |
| D1110 |
Prophylaxis - adult |
556 |
556 |
$32K |
| D2332 |
|
225 |
131 |
$30K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
118 |
96 |
$24K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
116 |
94 |
$15K |
| D1510 |
|
70 |
64 |
$14K |
| D0272 |
Bitewings - two radiographic images |
481 |
481 |
$13K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
74 |
53 |
$12K |
| D0330 |
Panoramic radiographic image |
124 |
124 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
27 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$2K |