| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,072 |
6,054 |
$359K |
| D1120 |
Prophylaxis - child |
8,199 |
8,173 |
$308K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,739 |
2,732 |
$153K |
| D0230 |
Intraoral - periapical each additional radiographic image |
28,774 |
8,213 |
$118K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
930 |
548 |
$107K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,783 |
1,006 |
$101K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,149 |
8,122 |
$96K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,330 |
724 |
$89K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,176 |
668 |
$77K |
| D9248 |
|
2,209 |
2,068 |
$76K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
521 |
291 |
$52K |
| D0220 |
Intraoral - periapical first radiographic image |
3,596 |
3,453 |
$42K |
| D1351 |
Sealant - per tooth |
1,115 |
306 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
678 |
462 |
$35K |
| D0274 |
Bitewings - four radiographic images |
1,584 |
1,578 |
$32K |
| D2140 |
|
532 |
366 |
$29K |
| D0272 |
Bitewings - two radiographic images |
2,420 |
2,415 |
$29K |
| D0210 |
Intraoral - complete series of radiographic images |
584 |
581 |
$25K |
| D0350 |
|
2,373 |
1,433 |
$24K |
| D2330 |
|
60 |
36 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D9993 |
|
13 |
13 |
$845.00 |
| D9430 |
|
24 |
24 |
$768.00 |
| D0340 |
|
14 |
14 |
$700.00 |
| D1310 |
|
13 |
13 |
$598.00 |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$390.00 |