| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,376 |
5,364 |
$798K |
| D1351 |
Sealant - per tooth |
4,362 |
736 |
$117K |
| D9248 |
|
261 |
261 |
$96K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
874 |
365 |
$48K |
| D0272 |
Bitewings - two radiographic images |
4,974 |
4,963 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
213 |
213 |
$32K |
| D1120 |
Prophylaxis - child |
5,361 |
5,348 |
$27K |
| D2140 |
|
384 |
150 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
5,335 |
5,313 |
$11K |
| D1206 |
Topical application of fluoride varnish |
5,420 |
5,407 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
185 |
63 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
471 |
220 |
$8K |
| D0330 |
Panoramic radiographic image |
982 |
981 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
35 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
14 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
26 |
13 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$0.00 |