| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,123 |
6,104 |
$638K |
| D1351 |
Sealant - per tooth |
3,547 |
796 |
$126K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
767 |
756 |
$90K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
733 |
128 |
$88K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
986 |
419 |
$67K |
| D1120 |
Prophylaxis - child |
6,224 |
6,195 |
$55K |
| D7140 |
Extraction, erupted tooth or exposed root |
677 |
251 |
$51K |
| D0272 |
Bitewings - two radiographic images |
4,825 |
4,794 |
$43K |
| D1206 |
Topical application of fluoride varnish |
5,915 |
5,891 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
5,302 |
5,247 |
$17K |
| D2140 |
|
312 |
147 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,019 |
4,923 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
167 |
161 |
$7K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
74 |
26 |
$5K |
| D0330 |
Panoramic radiographic image |
371 |
371 |
$384.35 |
| D1208 |
Topical application of fluoride, excluding varnish |
217 |
214 |
$128.58 |