| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,600 |
4,600 |
$161K |
| D1110 |
Prophylaxis - adult |
2,352 |
2,352 |
$119K |
| D0120 |
Periodic oral evaluation - established patient |
4,792 |
4,792 |
$113K |
| D1206 |
Topical application of fluoride varnish |
6,588 |
6,588 |
$109K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,148 |
2,147 |
$88K |
| D0210 |
Intraoral - complete series of radiographic images |
1,134 |
1,134 |
$64K |
| D0274 |
Bitewings - four radiographic images |
1,963 |
1,963 |
$56K |
| D1351 |
Sealant - per tooth |
1,514 |
428 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
227 |
149 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,026 |
1,026 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
220 |
133 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
420 |
414 |
$16K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
111 |
62 |
$14K |
| D7111 |
|
207 |
135 |
$14K |
| D0330 |
Panoramic radiographic image |
281 |
281 |
$13K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
59 |
37 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
125 |
122 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
28 |
28 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
14 |
14 |
$226.80 |