| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,228 |
4,200 |
$284K |
| D1120 |
Prophylaxis - child |
5,103 |
5,071 |
$134K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
758 |
752 |
$77K |
| D0272 |
Bitewings - two radiographic images |
3,131 |
3,098 |
$63K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
665 |
245 |
$53K |
| D1351 |
Sealant - per tooth |
1,200 |
319 |
$47K |
| D0220 |
Intraoral - periapical first radiographic image |
3,889 |
3,827 |
$45K |
| D1206 |
Topical application of fluoride varnish |
5,200 |
5,166 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
443 |
255 |
$41K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
578 |
302 |
$39K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,682 |
3,590 |
$21K |
| D2140 |
|
329 |
211 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
273 |
165 |
$20K |
| D0274 |
Bitewings - four radiographic images |
335 |
333 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
143 |
143 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
133 |
72 |
$7K |
| D9420 |
|
12 |
12 |
$3K |
| D1110 |
Prophylaxis - adult |
15 |
14 |
$744.08 |
| D1999 |
|
53 |
52 |
$562.08 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
23 |
13 |
$0.00 |