| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,276 |
8,179 |
$318K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,679 |
1,537 |
$250K |
| D0120 |
Periodic oral evaluation - established patient |
6,040 |
5,960 |
$187K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,098 |
7,995 |
$179K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,337 |
3,301 |
$178K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,700 |
1,107 |
$131K |
| D0272 |
Bitewings - two radiographic images |
4,943 |
4,869 |
$116K |
| D1351 |
Sealant - per tooth |
2,940 |
872 |
$85K |
| D0220 |
Intraoral - periapical first radiographic image |
4,070 |
4,011 |
$67K |
| D1110 |
Prophylaxis - adult |
1,175 |
1,148 |
$67K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,494 |
3,438 |
$57K |
| D1206 |
Topical application of fluoride varnish |
1,151 |
1,144 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
51 |
41 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
63 |
53 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
25 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
43 |
30 |
$2K |
| D7111 |
|
15 |
12 |
$967.35 |
| D9986 |
|
199 |
192 |
$0.00 |