| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,829 |
5,740 |
$451K |
| D0220 |
Intraoral - periapical first radiographic image |
3,415 |
3,297 |
$116K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
853 |
831 |
$88K |
| D1120 |
Prophylaxis - child |
6,539 |
6,426 |
$88K |
| D1351 |
Sealant - per tooth |
1,202 |
364 |
$40K |
| D1206 |
Topical application of fluoride varnish |
6,371 |
6,255 |
$32K |
| D7140 |
Extraction, erupted tooth or exposed root |
407 |
197 |
$24K |
| D0272 |
Bitewings - two radiographic images |
2,191 |
2,147 |
$19K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,375 |
2,904 |
$17K |
| D2140 |
|
294 |
176 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
244 |
146 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
174 |
107 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
279 |
73 |
$12K |
| D0330 |
Panoramic radiographic image |
475 |
463 |
$11K |
| D0140 |
Limited oral evaluation - problem focused |
206 |
190 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
90 |
68 |
$4K |
| D1999 |
|
185 |
177 |
$2K |
| D1110 |
Prophylaxis - adult |
55 |
55 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
267 |
231 |
$1K |
| D0274 |
Bitewings - four radiographic images |
40 |
38 |
$1K |