| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,444 |
3,399 |
$313K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
723 |
339 |
$65K |
| D1120 |
Prophylaxis - child |
3,308 |
3,278 |
$57K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
402 |
398 |
$41K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
689 |
317 |
$40K |
| D1351 |
Sealant - per tooth |
738 |
351 |
$36K |
| D1206 |
Topical application of fluoride varnish |
3,497 |
3,468 |
$35K |
| D0272 |
Bitewings - two radiographic images |
2,516 |
2,478 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
398 |
243 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
4,071 |
3,986 |
$28K |
| D2140 |
|
410 |
234 |
$26K |
| D7140 |
Extraction, erupted tooth or exposed root |
508 |
219 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,875 |
3,780 |
$20K |
| D0274 |
Bitewings - four radiographic images |
1,214 |
1,200 |
$20K |
| D0330 |
Panoramic radiographic image |
182 |
182 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
178 |
73 |
$8K |
| D1110 |
Prophylaxis - adult |
228 |
223 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
25 |
13 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$451.57 |