| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
18,577 |
17,809 |
$511K |
| D1120 |
Prophylaxis - child |
12,902 |
12,346 |
$371K |
| D1206 |
Topical application of fluoride varnish |
20,941 |
19,958 |
$348K |
| D1110 |
Prophylaxis - adult |
5,621 |
5,280 |
$226K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
861 |
190 |
$132K |
| D0272 |
Bitewings - two radiographic images |
5,151 |
4,822 |
$98K |
| D0220 |
Intraoral - periapical first radiographic image |
4,832 |
4,308 |
$71K |
| D0274 |
Bitewings - four radiographic images |
1,980 |
1,815 |
$68K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
839 |
527 |
$67K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,397 |
1,293 |
$62K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,188 |
3,300 |
$60K |
| D1351 |
Sealant - per tooth |
1,680 |
383 |
$38K |
| D7140 |
Extraction, erupted tooth or exposed root |
505 |
178 |
$35K |
| D9420 |
|
229 |
228 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
13 |
$2K |
| 99199 |
Unlisted special service, procedure or report |
34 |
34 |
$163.44 |