| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
6,744 |
6,502 |
$736K |
| D9248 |
|
532 |
514 |
$195K |
| D1351 |
Sealant - per tooth |
3,839 |
1,049 |
$106K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
709 |
683 |
$88K |
| D1120 |
Prophylaxis - child |
7,205 |
6,952 |
$72K |
| D0272 |
Bitewings - two radiographic images |
6,496 |
6,263 |
$49K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,475 |
717 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
6,836 |
6,582 |
$37K |
| D2140 |
|
1,147 |
531 |
$36K |
| D1206 |
Topical application of fluoride varnish |
7,121 |
6,888 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
219 |
100 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
727 |
332 |
$11K |
| D0330 |
Panoramic radiographic image |
1,140 |
1,092 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
242 |
105 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
70 |
66 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
24 |
$3K |
| D1110 |
Prophylaxis - adult |
129 |
128 |
$842.42 |
| D2160 |
|
14 |
12 |
$307.90 |
| D2332 |
|
20 |
13 |
$286.38 |
| D1353 |
|
48 |
24 |
$200.14 |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
12 |
$0.00 |
| D1999 |
|
15 |
13 |
$0.00 |