| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,285 |
8,285 |
$300K |
| D1351 |
Sealant - per tooth |
6,612 |
2,187 |
$234K |
| D0120 |
Periodic oral evaluation - established patient |
9,180 |
9,180 |
$219K |
| D1206 |
Topical application of fluoride varnish |
4,439 |
4,439 |
$106K |
| D1110 |
Prophylaxis - adult |
1,783 |
1,783 |
$83K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,909 |
1,350 |
$82K |
| D0272 |
Bitewings - two radiographic images |
5,798 |
5,798 |
$76K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,795 |
5,795 |
$69K |
| D0274 |
Bitewings - four radiographic images |
2,952 |
2,952 |
$66K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
970 |
529 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
4,544 |
4,511 |
$48K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
444 |
251 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
933 |
933 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,987 |
2,986 |
$17K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
247 |
146 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
338 |
247 |
$13K |
| D1354 |
|
498 |
97 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
371 |
369 |
$5K |
| D2332 |
|
17 |
17 |
$3K |