| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,066 |
2,060 |
$161K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
622 |
621 |
$52K |
| D1351 |
Sealant - per tooth |
2,103 |
338 |
$51K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
491 |
238 |
$42K |
| D1120 |
Prophylaxis - child |
2,361 |
2,355 |
$36K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
278 |
70 |
$26K |
| D1206 |
Topical application of fluoride varnish |
2,855 |
2,848 |
$21K |
| D2140 |
|
303 |
173 |
$20K |
| D0272 |
Bitewings - two radiographic images |
809 |
808 |
$16K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
99 |
42 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
107 |
107 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
111 |
46 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
178 |
176 |
$2K |
| D0274 |
Bitewings - four radiographic images |
185 |
185 |
$1K |
| D1110 |
Prophylaxis - adult |
79 |
79 |
$949.66 |
| D9420 |
|
24 |
24 |
$122.97 |
| D0230 |
Intraoral - periapical each additional radiographic image |
16 |
14 |
$0.00 |