| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,440 |
5,438 |
$203K |
| D0120 |
Periodic oral evaluation - established patient |
6,607 |
6,603 |
$164K |
| D1351 |
Sealant - per tooth |
3,401 |
1,174 |
$130K |
| D0274 |
Bitewings - four radiographic images |
4,449 |
4,447 |
$110K |
| D0220 |
Intraoral - periapical first radiographic image |
5,946 |
5,865 |
$89K |
| D1206 |
Topical application of fluoride varnish |
3,231 |
3,227 |
$85K |
| D1354 |
|
2,520 |
749 |
$78K |
| D1110 |
Prophylaxis - adult |
1,152 |
1,152 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
731 |
452 |
$47K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,765 |
3,764 |
$47K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
394 |
247 |
$44K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
374 |
237 |
$31K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,023 |
2,876 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
427 |
288 |
$24K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
117 |
77 |
$6K |
| D0272 |
Bitewings - two radiographic images |
338 |
338 |
$5K |
| D1320 |
|
576 |
576 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
55 |
40 |
$4K |
| D2335 |
|
19 |
13 |
$3K |
| D0240 |
|
127 |
72 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
141 |
140 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$1K |
| D0250 |
|
15 |
15 |
$406.60 |