| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,936 |
5,886 |
$514K |
| D1351 |
Sealant - per tooth |
6,158 |
1,146 |
$163K |
| D1120 |
Prophylaxis - child |
6,039 |
5,968 |
$69K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
456 |
435 |
$54K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
931 |
482 |
$39K |
| D0272 |
Bitewings - two radiographic images |
3,981 |
3,922 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
429 |
192 |
$35K |
| D1206 |
Topical application of fluoride varnish |
6,298 |
6,220 |
$32K |
| D0274 |
Bitewings - four radiographic images |
1,386 |
1,375 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
862 |
826 |
$13K |
| D0330 |
Panoramic radiographic image |
365 |
361 |
$12K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
91 |
41 |
$4K |
| D1110 |
Prophylaxis - adult |
168 |
163 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
131 |
76 |
$2K |
| D2140 |
|
68 |
40 |
$1K |
| D1999 |
|
21 |
17 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
215 |
195 |
$988.81 |