| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,597 |
3,580 |
$256K |
| D1120 |
Prophylaxis - child |
3,783 |
3,743 |
$177K |
| D0272 |
Bitewings - two radiographic images |
2,636 |
2,609 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
562 |
159 |
$30K |
| D1351 |
Sealant - per tooth |
558 |
122 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
108 |
108 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
2,220 |
2,202 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
275 |
137 |
$10K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
201 |
143 |
$9K |
| D2140 |
|
51 |
42 |
$5K |
| D1206 |
Topical application of fluoride varnish |
3,796 |
3,756 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
50 |
$3K |
| D1110 |
Prophylaxis - adult |
13 |
13 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D9420 |
|
13 |
13 |
$1K |
| D0330 |
Panoramic radiographic image |
142 |
140 |
$849.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,920 |
1,912 |
$533.04 |
| D0274 |
Bitewings - four radiographic images |
745 |
744 |
$476.14 |
| D1208 |
Topical application of fluoride, excluding varnish |
25 |
25 |
$0.00 |