| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,414 |
1,397 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
639 |
286 |
$57K |
| D1120 |
Prophylaxis - child |
1,498 |
1,481 |
$53K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
336 |
334 |
$31K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
386 |
199 |
$26K |
| D1351 |
Sealant - per tooth |
571 |
114 |
$22K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
263 |
145 |
$19K |
| D1206 |
Topical application of fluoride varnish |
1,648 |
1,633 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,750 |
1,245 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,376 |
1,348 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
70 |
15 |
$9K |
| D2140 |
|
169 |
119 |
$8K |
| D0272 |
Bitewings - two radiographic images |
736 |
727 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
229 |
139 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
58 |
32 |
$6K |
| D0274 |
Bitewings - four radiographic images |
373 |
369 |
$5K |
| D1110 |
Prophylaxis - adult |
92 |
92 |
$4K |
| D0330 |
Panoramic radiographic image |
214 |
214 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
13 |
$880.08 |