| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
8,827 |
8,763 |
$531K |
| D1120 |
Prophylaxis - child |
12,094 |
12,003 |
$483K |
| D1351 |
Sealant - per tooth |
13,507 |
4,426 |
$391K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,527 |
3,514 |
$230K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
3,368 |
2,228 |
$223K |
| D0274 |
Bitewings - four radiographic images |
5,789 |
5,743 |
$123K |
| D1206 |
Topical application of fluoride varnish |
11,161 |
11,082 |
$121K |
| D7111 |
|
1,438 |
1,058 |
$82K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
662 |
487 |
$79K |
| D0272 |
Bitewings - two radiographic images |
5,247 |
5,214 |
$63K |
| D0230 |
Intraoral - periapical each additional radiographic image |
11,819 |
2,744 |
$49K |
| D1310 |
|
889 |
879 |
$39K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
622 |
442 |
$34K |
| D1510 |
|
222 |
164 |
$33K |
| D9430 |
|
1,020 |
999 |
$33K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
425 |
333 |
$33K |
| D3240 |
|
265 |
210 |
$26K |
| D0220 |
Intraoral - periapical first radiographic image |
2,134 |
2,061 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
516 |
515 |
$24K |
| D0350 |
|
1,016 |
669 |
$9K |
| D0601 |
|
630 |
625 |
$8K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
111 |
82 |
$7K |
| D2140 |
|
42 |
25 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
14 |
14 |
$826.00 |
| D0250 |
|
30 |
28 |
$638.00 |
| D0603 |
|
42 |
42 |
$600.00 |