| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,868 |
2,833 |
$148K |
| D0272 |
Bitewings - two radiographic images |
1,492 |
1,455 |
$82K |
| D1120 |
Prophylaxis - child |
3,534 |
3,469 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
1,248 |
1,202 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
480 |
465 |
$25K |
| D1206 |
Topical application of fluoride varnish |
3,621 |
3,547 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,010 |
873 |
$7K |
| D1351 |
Sealant - per tooth |
140 |
43 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
47 |
15 |
$4K |
| D0274 |
Bitewings - four radiographic images |
72 |
71 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
54 |
25 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
93 |
49 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
22 |
12 |
$510.96 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$491.76 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$456.25 |