| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,267 |
6,073 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
7,066 |
6,865 |
$129K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,643 |
992 |
$116K |
| D1351 |
Sealant - per tooth |
4,385 |
806 |
$90K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,750 |
5,556 |
$87K |
| D1110 |
Prophylaxis - adult |
1,957 |
1,902 |
$71K |
| D0330 |
Panoramic radiographic image |
1,421 |
1,377 |
$59K |
| D0272 |
Bitewings - two radiographic images |
3,372 |
3,268 |
$57K |
| D1206 |
Topical application of fluoride varnish |
2,585 |
2,522 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
592 |
280 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
307 |
160 |
$31K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
581 |
393 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,145 |
1,100 |
$27K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
194 |
93 |
$11K |
| D2335 |
|
63 |
25 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
92 |
$2K |
| D2330 |
|
38 |
24 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
34 |
$2K |