| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,703 |
1,665 |
$158K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
421 |
415 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
1,585 |
1,526 |
$33K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
514 |
176 |
$32K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
369 |
194 |
$21K |
| D1120 |
Prophylaxis - child |
2,179 |
2,137 |
$16K |
| D0272 |
Bitewings - two radiographic images |
1,323 |
1,282 |
$14K |
| D2140 |
|
188 |
128 |
$14K |
| D1351 |
Sealant - per tooth |
229 |
84 |
$13K |
| D1206 |
Topical application of fluoride varnish |
2,113 |
2,077 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,668 |
1,387 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
64 |
36 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
14 |
14 |
$882.47 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
57 |
53 |
$150.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
19 |
18 |
$120.00 |