| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,874 |
11,872 |
$441K |
| D0120 |
Periodic oral evaluation - established patient |
14,417 |
14,414 |
$397K |
| D1208 |
Topical application of fluoride, excluding varnish |
14,416 |
14,414 |
$218K |
| D1351 |
Sealant - per tooth |
5,694 |
1,870 |
$218K |
| D1110 |
Prophylaxis - adult |
2,683 |
2,680 |
$131K |
| D7140 |
Extraction, erupted tooth or exposed root |
1,977 |
1,499 |
$108K |
| D0272 |
Bitewings - two radiographic images |
5,703 |
5,702 |
$90K |
| D0330 |
Panoramic radiographic image |
2,080 |
2,080 |
$86K |
| D0220 |
Intraoral - periapical first radiographic image |
6,870 |
6,831 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
919 |
539 |
$68K |
| D0274 |
Bitewings - four radiographic images |
1,247 |
1,247 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,836 |
3,829 |
$27K |
| D0140 |
Limited oral evaluation - problem focused |
817 |
808 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
213 |
150 |
$11K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
25 |
17 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
18 |
14 |
$2K |
| D0601 |
|
29 |
29 |
$290.00 |
| D1999 |
|
41 |
41 |
$0.00 |