| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,383 |
8,096 |
$314K |
| D1208 |
Topical application of fluoride, excluding varnish |
9,534 |
9,169 |
$220K |
| D0120 |
Periodic oral evaluation - established patient |
8,426 |
8,125 |
$208K |
| D1351 |
Sealant - per tooth |
2,444 |
706 |
$80K |
| D0330 |
Panoramic radiographic image |
1,721 |
1,639 |
$45K |
| D0272 |
Bitewings - two radiographic images |
4,217 |
4,056 |
$43K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,654 |
1,597 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
377 |
268 |
$23K |
| D1110 |
Prophylaxis - adult |
672 |
608 |
$18K |
| D0140 |
Limited oral evaluation - problem focused |
375 |
361 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
52 |
$5K |
| D2394 |
|
30 |
26 |
$3K |
| D0274 |
Bitewings - four radiographic images |
113 |
113 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
25 |
12 |
$222.00 |
| D0220 |
Intraoral - periapical first radiographic image |
51 |
49 |
$171.89 |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
73 |
13 |
$0.00 |
| D1999 |
|
39 |
30 |
$0.00 |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
144 |
25 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
13 |
12 |
$0.00 |