| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
10,949 |
10,938 |
$617K |
| D1120 |
Prophylaxis - child |
14,294 |
14,274 |
$550K |
| D1351 |
Sealant - per tooth |
14,469 |
3,217 |
$402K |
| D1206 |
Topical application of fluoride varnish |
11,867 |
11,860 |
$170K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,328 |
884 |
$152K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,357 |
368 |
$148K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,402 |
381 |
$129K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,110 |
2,106 |
$127K |
| D0274 |
Bitewings - four radiographic images |
5,422 |
5,418 |
$113K |
| D0230 |
Intraoral - periapical each additional radiographic image |
17,550 |
13,383 |
$104K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,679 |
837 |
$95K |
| D1310 |
|
2,003 |
2,001 |
$91K |
| D0145 |
Oral evaluation for a patient under three years of age |
1,058 |
1,058 |
$63K |
| D0272 |
Bitewings - two radiographic images |
5,435 |
5,417 |
$61K |
| D0220 |
Intraoral - periapical first radiographic image |
3,775 |
3,705 |
$44K |
| D2160 |
|
487 |
237 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,562 |
2,546 |
$29K |
| D9430 |
|
899 |
880 |
$28K |
| D2140 |
|
525 |
293 |
$28K |
| D0603 |
|
1,679 |
1,677 |
$22K |
| D9248 |
|
589 |
574 |
$20K |
| D0350 |
|
974 |
757 |
$16K |
| D9920 |
|
48 |
46 |
$5K |
| D2330 |
|
55 |
26 |
$4K |
| D9110 |
|
54 |
52 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
47 |
31 |
$3K |
| D0601 |
|
212 |
212 |
$3K |
| D2161 |
|
18 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
13 |
$1K |
| D9994 |
|
103 |
103 |
$0.00 |