| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,062 |
7,851 |
$167K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,128 |
7,913 |
$127K |
| D0120 |
Periodic oral evaluation - established patient |
6,691 |
6,527 |
$119K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
568 |
122 |
$56K |
| D0272 |
Bitewings - two radiographic images |
5,368 |
5,226 |
$56K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,812 |
1,763 |
$50K |
| D7140 |
Extraction, erupted tooth or exposed root |
667 |
303 |
$37K |
| D1351 |
Sealant - per tooth |
1,636 |
511 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
583 |
385 |
$32K |
| D0240 |
|
2,346 |
1,366 |
$31K |
| D0330 |
Panoramic radiographic image |
427 |
423 |
$20K |
| D0274 |
Bitewings - four radiographic images |
867 |
861 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
107 |
75 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
225 |
214 |
$5K |
| D1110 |
Prophylaxis - adult |
88 |
87 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
43 |
13 |
$3K |
| D1206 |
Topical application of fluoride varnish |
82 |
82 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
68 |
66 |
$351.00 |