| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,754 |
3,730 |
$359K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
733 |
343 |
$51K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
570 |
119 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
3,867 |
3,829 |
$38K |
| D1120 |
Prophylaxis - child |
3,828 |
3,800 |
$30K |
| D1351 |
Sealant - per tooth |
1,062 |
137 |
$30K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
257 |
256 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
332 |
80 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
266 |
147 |
$18K |
| D9420 |
|
170 |
168 |
$16K |
| D0272 |
Bitewings - two radiographic images |
2,007 |
1,989 |
$15K |
| D2140 |
|
265 |
164 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
104 |
104 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,672 |
3,561 |
$3K |
| D0330 |
Panoramic radiographic image |
182 |
182 |
$1K |
| D1206 |
Topical application of fluoride varnish |
4,021 |
3,992 |
$854.34 |
| D1110 |
Prophylaxis - adult |
177 |
177 |
$601.16 |
| D0274 |
Bitewings - four radiographic images |
464 |
464 |
$189.42 |