| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,203 |
3,161 |
$241K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,020 |
379 |
$53K |
| D0272 |
Bitewings - two radiographic images |
3,288 |
3,240 |
$25K |
| D1120 |
Prophylaxis - child |
3,073 |
3,029 |
$23K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
305 |
120 |
$16K |
| D1351 |
Sealant - per tooth |
546 |
82 |
$15K |
| D2140 |
|
309 |
154 |
$7K |
| D1206 |
Topical application of fluoride varnish |
1,749 |
1,742 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
57 |
57 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
29 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
55 |
$1K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
39 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
81 |
80 |
$831.77 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
26 |
$133.46 |
| D1110 |
Prophylaxis - adult |
63 |
63 |
$65.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
51 |
48 |
$0.00 |