| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
5,465 |
5,413 |
$466K |
| D1120 |
Prophylaxis - child |
5,189 |
5,156 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
721 |
718 |
$68K |
| D0272 |
Bitewings - two radiographic images |
2,195 |
2,172 |
$57K |
| D1351 |
Sealant - per tooth |
1,403 |
246 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
495 |
238 |
$41K |
| D1206 |
Topical application of fluoride varnish |
6,021 |
5,969 |
$37K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
958 |
397 |
$37K |
| D0330 |
Panoramic radiographic image |
1,022 |
1,009 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
212 |
141 |
$15K |
| D1110 |
Prophylaxis - adult |
616 |
603 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
681 |
669 |
$11K |
| D2140 |
|
295 |
185 |
$10K |
| D0274 |
Bitewings - four radiographic images |
709 |
699 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
984 |
421 |
$9K |
| D7111 |
|
216 |
140 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
60 |
25 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$399.83 |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
15 |
12 |
$0.00 |