| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
10,327 |
10,322 |
$362K |
| D0120 |
Periodic oral evaluation - established patient |
13,976 |
13,964 |
$311K |
| D1110 |
Prophylaxis - adult |
6,542 |
6,533 |
$276K |
| D1351 |
Sealant - per tooth |
4,191 |
1,896 |
$226K |
| D0220 |
Intraoral - periapical first radiographic image |
14,317 |
14,285 |
$138K |
| D0272 |
Bitewings - two radiographic images |
9,826 |
9,825 |
$129K |
| D1206 |
Topical application of fluoride varnish |
4,888 |
4,885 |
$119K |
| D0230 |
Intraoral - periapical each additional radiographic image |
13,211 |
13,197 |
$100K |
| D1208 |
Topical application of fluoride, excluding varnish |
7,918 |
7,916 |
$93K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,139 |
941 |
$76K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,116 |
3,116 |
$75K |
| D0210 |
Intraoral - complete series of radiographic images |
1,721 |
1,719 |
$35K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
733 |
592 |
$30K |
| D0274 |
Bitewings - four radiographic images |
939 |
932 |
$20K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
121 |
98 |
$12K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
101 |
83 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
408 |
406 |
$5K |
| D3240 |
|
17 |
14 |
$3K |
| D1354 |
|
93 |
66 |
$2K |
| D0330 |
Panoramic radiographic image |
60 |
60 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
19 |
$737.68 |
| D0270 |
|
17 |
17 |
$175.06 |