| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
7,437 |
7,387 |
$744K |
| D1351 |
Sealant - per tooth |
5,937 |
1,085 |
$144K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
2,075 |
951 |
$114K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
735 |
723 |
$87K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,101 |
265 |
$82K |
| D1120 |
Prophylaxis - child |
7,614 |
7,565 |
$49K |
| D0272 |
Bitewings - two radiographic images |
5,531 |
5,493 |
$40K |
| D2140 |
|
741 |
410 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
229 |
97 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
562 |
273 |
$21K |
| D0140 |
Limited oral evaluation - problem focused |
321 |
309 |
$20K |
| D1206 |
Topical application of fluoride varnish |
7,947 |
7,891 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,051 |
1,034 |
$12K |
| D0274 |
Bitewings - four radiographic images |
1,628 |
1,614 |
$10K |
| D0330 |
Panoramic radiographic image |
613 |
608 |
$7K |
| D1110 |
Prophylaxis - adult |
477 |
469 |
$3K |
| D2332 |
|
21 |
13 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
482 |
457 |
$1K |