| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
21,089 |
21,052 |
$676K |
| D0120 |
Periodic oral evaluation - established patient |
25,822 |
25,780 |
$565K |
| D0274 |
Bitewings - four radiographic images |
22,392 |
22,389 |
$465K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
5,661 |
4,404 |
$335K |
| D1208 |
Topical application of fluoride, excluding varnish |
24,753 |
24,712 |
$278K |
| D0220 |
Intraoral - periapical first radiographic image |
24,748 |
24,709 |
$271K |
| D1351 |
Sealant - per tooth |
4,365 |
2,250 |
$222K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
2,422 |
2,072 |
$207K |
| D7140 |
Extraction, erupted tooth or exposed root |
4,699 |
3,701 |
$192K |
| D1110 |
Prophylaxis - adult |
3,798 |
3,796 |
$153K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
3,826 |
2,994 |
$151K |
| D0230 |
Intraoral - periapical each additional radiographic image |
23,896 |
23,879 |
$127K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
727 |
664 |
$43K |
| D1206 |
Topical application of fluoride varnish |
1,057 |
1,057 |
$27K |
| D9310 |
|
285 |
285 |
$13K |
| D9990 |
|
518 |
512 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
564 |
554 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
47 |
47 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$502.60 |
| D1999 |
|
218 |
218 |
$0.00 |