| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,225 |
6,817 |
$180K |
| D0120 |
Periodic oral evaluation - established patient |
6,210 |
5,859 |
$117K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,515 |
7,086 |
$116K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,016 |
284 |
$101K |
| D0272 |
Bitewings - two radiographic images |
2,676 |
2,550 |
$43K |
| D0140 |
Limited oral evaluation - problem focused |
1,250 |
1,190 |
$33K |
| D9420 |
|
625 |
609 |
$21K |
| D0240 |
|
1,568 |
794 |
$16K |
| D1351 |
Sealant - per tooth |
836 |
212 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
229 |
98 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,940 |
600 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
917 |
874 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
145 |
60 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
97 |
40 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
234 |
221 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
114 |
50 |
$5K |
| D1110 |
Prophylaxis - adult |
43 |
40 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$729.26 |
| D1999 |
|
1,280 |
1,195 |
$0.00 |