| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,003 |
5,998 |
$449K |
| D1120 |
Prophylaxis - child |
5,987 |
5,984 |
$112K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,073 |
573 |
$100K |
| D1351 |
Sealant - per tooth |
3,652 |
597 |
$98K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,022 |
588 |
$87K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,062 |
1,062 |
$80K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
961 |
569 |
$73K |
| D2140 |
|
721 |
467 |
$66K |
| D1206 |
Topical application of fluoride varnish |
6,708 |
6,704 |
$59K |
| D0272 |
Bitewings - two radiographic images |
4,923 |
4,913 |
$59K |
| D0274 |
Bitewings - four radiographic images |
1,202 |
1,200 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,203 |
1,185 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,675 |
1,650 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
257 |
144 |
$19K |
| D1110 |
Prophylaxis - adult |
530 |
523 |
$11K |
| D0330 |
Panoramic radiographic image |
411 |
411 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
32 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
64 |
64 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
330 |
328 |
$230.00 |
| D9420 |
|
13 |
13 |
$0.00 |