| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
10,067 |
10,062 |
$449K |
| D1120 |
Prophylaxis - child |
11,224 |
11,210 |
$349K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
5,000 |
2,643 |
$336K |
| D0230 |
Intraoral - periapical each additional radiographic image |
61,395 |
12,006 |
$246K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,832 |
581 |
$215K |
| D2140 |
|
3,083 |
1,943 |
$168K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,259 |
419 |
$125K |
| D1208 |
Topical application of fluoride, excluding varnish |
11,276 |
11,262 |
$96K |
| D0274 |
Bitewings - four radiographic images |
4,335 |
4,335 |
$92K |
| D0272 |
Bitewings - two radiographic images |
4,637 |
4,632 |
$54K |
| D0350 |
|
4,125 |
2,481 |
$41K |
| D9248 |
|
1,002 |
1,001 |
$35K |
| D2160 |
|
418 |
313 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,836 |
2,815 |
$33K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
502 |
502 |
$30K |
| D1351 |
Sealant - per tooth |
1,061 |
398 |
$25K |
| D2330 |
|
260 |
133 |
$20K |
| D1310 |
|
165 |
165 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
41 |
25 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
32 |
32 |
$2K |
| D0603 |
|
68 |
68 |
$1K |