| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
9,364 |
9,307 |
$862K |
| D1120 |
Prophylaxis - child |
9,380 |
9,320 |
$111K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
710 |
690 |
$83K |
| D1351 |
Sealant - per tooth |
3,034 |
569 |
$76K |
| D0220 |
Intraoral - periapical first radiographic image |
5,386 |
5,265 |
$74K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,332 |
833 |
$68K |
| D0272 |
Bitewings - two radiographic images |
4,935 |
4,893 |
$60K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
621 |
335 |
$58K |
| D1206 |
Topical application of fluoride varnish |
9,448 |
9,400 |
$51K |
| D2140 |
|
952 |
614 |
$41K |
| D0140 |
Limited oral evaluation - problem focused |
528 |
499 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
235 |
138 |
$18K |
| D0230 |
Intraoral - periapical each additional radiographic image |
6,036 |
4,502 |
$18K |
| D0274 |
Bitewings - four radiographic images |
1,443 |
1,421 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
456 |
279 |
$17K |
| D0210 |
Intraoral - complete series of radiographic images |
776 |
772 |
$7K |
| D9248 |
|
49 |
48 |
$5K |
| D1110 |
Prophylaxis - adult |
328 |
315 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
79 |
39 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
280 |
279 |
$362.00 |
| D0330 |
Panoramic radiographic image |
48 |
45 |
$115.02 |
| D0270 |
|
12 |
12 |
$0.00 |