| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,215 |
4,932 |
$311K |
| D0120 |
Periodic oral evaluation - established patient |
6,016 |
5,699 |
$270K |
| D1206 |
Topical application of fluoride varnish |
10,204 |
9,428 |
$268K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,487 |
746 |
$249K |
| D1351 |
Sealant - per tooth |
4,033 |
1,205 |
$186K |
| D0140 |
Limited oral evaluation - problem focused |
2,895 |
2,713 |
$175K |
| D0330 |
Panoramic radiographic image |
1,154 |
1,062 |
$103K |
| D0272 |
Bitewings - two radiographic images |
2,487 |
2,363 |
$95K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
453 |
126 |
$86K |
| D1110 |
Prophylaxis - adult |
1,072 |
1,001 |
$85K |
| D7140 |
Extraction, erupted tooth or exposed root |
446 |
183 |
$55K |
| D0274 |
Bitewings - four radiographic images |
713 |
648 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
474 |
436 |
$29K |
| D0220 |
Intraoral - periapical first radiographic image |
1,233 |
1,132 |
$28K |
| D7240 |
Removal of impacted tooth - completely bony |
105 |
12 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
77 |
27 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
74 |
40 |
$9K |
| D0240 |
|
88 |
85 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
201 |
106 |
$4K |
| D1999 |
|
608 |
559 |
$0.00 |
| D0603 |
|
29 |
29 |
$0.00 |
| D0171 |
|
12 |
12 |
$0.00 |
| D0601 |
|
18 |
18 |
$0.00 |