| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,347 |
2,337 |
$203K |
| D9420 |
|
693 |
667 |
$188K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
567 |
564 |
$78K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
550 |
136 |
$28K |
| D1120 |
Prophylaxis - child |
3,118 |
3,101 |
$26K |
| D1206 |
Topical application of fluoride varnish |
3,154 |
3,140 |
$13K |
| D0272 |
Bitewings - two radiographic images |
918 |
905 |
$11K |
| D1351 |
Sealant - per tooth |
565 |
185 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
501 |
490 |
$8K |
| D2140 |
|
111 |
62 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
163 |
79 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
38 |
$2K |
| D0274 |
Bitewings - four radiographic images |
139 |
139 |
$1K |
| D0330 |
Panoramic radiographic image |
228 |
225 |
$427.50 |
| D0230 |
Intraoral - periapical each additional radiographic image |
322 |
301 |
$99.20 |