| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,746 |
1,726 |
$92K |
| D0140 |
Limited oral evaluation - problem focused |
1,071 |
1,055 |
$75K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,109 |
1,018 |
$59K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
540 |
540 |
$20K |
| D2940 |
|
436 |
421 |
$19K |
| D0603 |
|
834 |
834 |
$17K |
| D1120 |
Prophylaxis - child |
1,298 |
1,297 |
$2K |
| D1206 |
Topical application of fluoride varnish |
1,268 |
1,268 |
$941.85 |
| D0602 |
|
195 |
195 |
$752.34 |
| D0601 |
|
144 |
144 |
$209.30 |
| D0230 |
Intraoral - periapical each additional radiographic image |
159 |
155 |
$0.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
76 |
73 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
555 |
555 |
$0.00 |
| D1351 |
Sealant - per tooth |
222 |
218 |
$0.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
215 |
202 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
453 |
438 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
131 |
123 |
$0.00 |
| D0330 |
Panoramic radiographic image |
242 |
242 |
$0.00 |
| D1354 |
|
111 |
111 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$0.00 |