| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
11,880 |
11,869 |
$455K |
| D0120 |
Periodic oral evaluation - established patient |
13,585 |
13,574 |
$349K |
| D1351 |
Sealant - per tooth |
9,166 |
3,204 |
$346K |
| D1110 |
Prophylaxis - adult |
2,720 |
2,720 |
$136K |
| D1206 |
Topical application of fluoride varnish |
5,423 |
5,423 |
$134K |
| D0272 |
Bitewings - two radiographic images |
7,943 |
7,938 |
$116K |
| D0274 |
Bitewings - four radiographic images |
4,596 |
4,595 |
$113K |
| D1208 |
Topical application of fluoride, excluding varnish |
8,912 |
8,908 |
$112K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,090 |
1,655 |
$109K |
| D0220 |
Intraoral - periapical first radiographic image |
6,665 |
6,633 |
$79K |
| D9999 |
Unspecified adjunctive procedure, by report |
449 |
449 |
$43K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
572 |
286 |
$33K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,194 |
4,192 |
$26K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
861 |
861 |
$22K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
133 |
80 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
84 |
52 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
435 |
434 |
$5K |
| D1354 |
|
211 |
40 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
44 |
27 |
$2K |
| D0601 |
|
1,401 |
1,399 |
$1K |
| D0602 |
|
797 |
794 |
$676.00 |
| D0603 |
|
577 |
577 |
$387.00 |