| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,894 |
5,894 |
$173K |
| D1120 |
Prophylaxis - child |
4,823 |
4,823 |
$146K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,775 |
808 |
$143K |
| D0272 |
Bitewings - two radiographic images |
3,669 |
3,669 |
$73K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,453 |
5,453 |
$69K |
| D0274 |
Bitewings - four radiographic images |
1,971 |
1,971 |
$65K |
| D1351 |
Sealant - per tooth |
2,019 |
754 |
$60K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,055 |
637 |
$57K |
| D1110 |
Prophylaxis - adult |
859 |
859 |
$36K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
462 |
276 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
485 |
298 |
$26K |
| D2160 |
|
374 |
282 |
$26K |
| D0140 |
Limited oral evaluation - problem focused |
632 |
630 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
1,128 |
1,124 |
$14K |
| D7140 |
Extraction, erupted tooth or exposed root |
219 |
151 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
750 |
750 |
$7K |
| D2332 |
|
49 |
29 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
14 |
$899.97 |
| D2330 |
|
18 |
14 |
$751.86 |