| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
24,058 |
24,058 |
$819K |
| D0120 |
Periodic oral evaluation - established patient |
20,945 |
20,945 |
$484K |
| D1351 |
Sealant - per tooth |
7,421 |
3,497 |
$369K |
| D1206 |
Topical application of fluoride varnish |
13,279 |
13,279 |
$324K |
| D0272 |
Bitewings - two radiographic images |
16,596 |
16,596 |
$220K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,160 |
1,521 |
$151K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,721 |
12,721 |
$145K |
| D0220 |
Intraoral - periapical first radiographic image |
11,423 |
11,388 |
$128K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,364 |
2,101 |
$113K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
4,582 |
4,582 |
$104K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
742 |
617 |
$73K |
| D0274 |
Bitewings - four radiographic images |
2,778 |
2,778 |
$62K |
| D1110 |
Prophylaxis - adult |
1,092 |
1,092 |
$50K |
| D0230 |
Intraoral - periapical each additional radiographic image |
7,660 |
7,658 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
1,318 |
1,310 |
$15K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
135 |
114 |
$10K |
| D1354 |
|
357 |
183 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
121 |
99 |
$5K |
| D9995 |
|
45 |
41 |
$939.20 |
| D9310 |
|
13 |
13 |
$487.20 |
| D0350 |
|
39 |
37 |
$410.50 |
| D0601 |
|
49 |
49 |
$49.00 |
| D0602 |
|
17 |
17 |
$17.00 |
| D0603 |
|
12 |
12 |
$8.00 |