| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,499 |
5,441 |
$296K |
| D1120 |
Prophylaxis - child |
6,373 |
6,310 |
$239K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,768 |
6,606 |
$139K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,032 |
843 |
$134K |
| D1208 |
Topical application of fluoride, excluding varnish |
6,725 |
6,660 |
$86K |
| D1351 |
Sealant - per tooth |
2,995 |
816 |
$78K |
| D0274 |
Bitewings - four radiographic images |
2,969 |
2,948 |
$63K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,007 |
526 |
$57K |
| D1310 |
|
1,029 |
1,020 |
$46K |
| D9993 |
|
598 |
596 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
2,864 |
2,786 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
491 |
487 |
$28K |
| D2140 |
|
510 |
211 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
288 |
108 |
$19K |
| D0350 |
|
739 |
617 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
134 |
49 |
$15K |
| D0272 |
Bitewings - two radiographic images |
905 |
902 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
103 |
39 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
160 |
55 |
$9K |
| D0603 |
|
342 |
342 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
108 |
108 |
$5K |
| D0601 |
|
111 |
111 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
26 |
25 |
$2K |
| D0602 |
|
13 |
13 |
$195.00 |