| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,586 |
2,573 |
$237K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
572 |
293 |
$52K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
245 |
245 |
$27K |
| D1351 |
Sealant - per tooth |
937 |
181 |
$18K |
| D1120 |
Prophylaxis - child |
2,566 |
2,556 |
$17K |
| D2140 |
|
179 |
118 |
$16K |
| D0272 |
Bitewings - two radiographic images |
2,257 |
2,239 |
$10K |
| D1206 |
Topical application of fluoride varnish |
2,521 |
2,515 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
102 |
26 |
$8K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
36 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
417 |
407 |
$1K |
| D0274 |
Bitewings - four radiographic images |
119 |
118 |
$674.05 |
| D9420 |
|
14 |
14 |
$367.44 |
| D0230 |
Intraoral - periapical each additional radiographic image |
216 |
159 |
$140.22 |
| D0330 |
Panoramic radiographic image |
165 |
162 |
$126.52 |
| D1208 |
Topical application of fluoride, excluding varnish |
351 |
345 |
$38.00 |
| D1110 |
Prophylaxis - adult |
37 |
36 |
$0.00 |