| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
7,053 |
7,034 |
$394K |
| D1120 |
Prophylaxis - child |
9,324 |
9,299 |
$363K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,842 |
1,157 |
$337K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
2,895 |
1,167 |
$286K |
| D1351 |
Sealant - per tooth |
7,616 |
2,258 |
$220K |
| D7140 |
Extraction, erupted tooth or exposed root |
3,590 |
1,859 |
$205K |
| D0230 |
Intraoral - periapical each additional radiographic image |
44,291 |
8,963 |
$186K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,617 |
1,099 |
$175K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,508 |
9,484 |
$136K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,605 |
1,605 |
$100K |
| D1310 |
|
2,035 |
2,030 |
$92K |
| D9993 |
|
1,035 |
1,034 |
$67K |
| D0220 |
Intraoral - periapical first radiographic image |
5,295 |
5,232 |
$63K |
| D2140 |
|
1,077 |
490 |
$59K |
| D0272 |
Bitewings - two radiographic images |
4,342 |
4,334 |
$51K |
| D0350 |
|
2,300 |
1,075 |
$25K |
| D0145 |
Oral evaluation for a patient under three years of age |
441 |
441 |
$23K |
| D0601 |
|
1,368 |
1,363 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
309 |
146 |
$17K |
| D1510 |
|
85 |
66 |
$9K |
| D2330 |
|
81 |
38 |
$6K |
| D2160 |
|
54 |
27 |
$4K |
| D0603 |
|
255 |
255 |
$4K |
| D9430 |
|
79 |
78 |
$3K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$400.00 |