| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,371 |
4,286 |
$398K |
| D1351 |
Sealant - per tooth |
2,583 |
518 |
$64K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
459 |
436 |
$55K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,015 |
446 |
$45K |
| D1120 |
Prophylaxis - child |
4,597 |
4,491 |
$40K |
| D0272 |
Bitewings - two radiographic images |
3,150 |
3,069 |
$27K |
| D2140 |
|
442 |
271 |
$23K |
| D1206 |
Topical application of fluoride varnish |
4,822 |
4,710 |
$17K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
220 |
87 |
$14K |
| D0274 |
Bitewings - four radiographic images |
817 |
804 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
569 |
541 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
67 |
$5K |
| D0330 |
Panoramic radiographic image |
270 |
260 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
27 |
27 |
$1K |
| D2160 |
|
41 |
26 |
$787.41 |
| D0230 |
Intraoral - periapical each additional radiographic image |
177 |
173 |
$175.77 |
| D1110 |
Prophylaxis - adult |
60 |
56 |
$0.00 |