| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
7,078 |
7,078 |
$256K |
| D0120 |
Periodic oral evaluation - established patient |
8,198 |
8,197 |
$200K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,842 |
1,090 |
$124K |
| D1206 |
Topical application of fluoride varnish |
4,532 |
4,527 |
$122K |
| D1351 |
Sealant - per tooth |
2,671 |
1,072 |
$115K |
| D0220 |
Intraoral - periapical first radiographic image |
6,748 |
6,704 |
$90K |
| D0274 |
Bitewings - four radiographic images |
2,951 |
2,951 |
$75K |
| D1354 |
|
1,873 |
664 |
$56K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,284 |
4,284 |
$53K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,981 |
4,971 |
$52K |
| D1110 |
Prophylaxis - adult |
989 |
989 |
$47K |
| D0210 |
Intraoral - complete series of radiographic images |
2,006 |
2,003 |
$38K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
604 |
383 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
523 |
385 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
147 |
104 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
144 |
110 |
$10K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
129 |
90 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
474 |
473 |
$6K |
| D9243 |
|
15 |
15 |
$3K |
| D1320 |
|
216 |
216 |
$2K |
| D0240 |
|
82 |
61 |
$2K |
| D0272 |
Bitewings - two radiographic images |
82 |
82 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
25 |
$727.96 |
| D9239 |
|
14 |
14 |
$567.46 |
| D9612 |
|
14 |
14 |
$0.00 |