| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,499 |
5,497 |
$370K |
| D1120 |
Prophylaxis - child |
5,516 |
5,514 |
$144K |
| D1351 |
Sealant - per tooth |
3,799 |
974 |
$124K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
550 |
108 |
$72K |
| D0272 |
Bitewings - two radiographic images |
3,590 |
3,586 |
$66K |
| D1206 |
Topical application of fluoride varnish |
5,108 |
5,105 |
$61K |
| D0220 |
Intraoral - periapical first radiographic image |
3,980 |
3,970 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
379 |
378 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,744 |
3,697 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
288 |
167 |
$27K |
| D7140 |
Extraction, erupted tooth or exposed root |
215 |
85 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
195 |
119 |
$14K |
| D0330 |
Panoramic radiographic image |
114 |
114 |
$5K |
| D2140 |
|
18 |
12 |
$953.96 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
26 |
$866.71 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$0.00 |