| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,906 |
4,897 |
$198K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,107 |
1,223 |
$126K |
| D0120 |
Periodic oral evaluation - established patient |
4,527 |
4,520 |
$124K |
| D1206 |
Topical application of fluoride varnish |
3,743 |
3,736 |
$84K |
| D1351 |
Sealant - per tooth |
1,845 |
590 |
$73K |
| D0272 |
Bitewings - two radiographic images |
3,454 |
3,450 |
$55K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
464 |
268 |
$51K |
| D0220 |
Intraoral - periapical first radiographic image |
3,688 |
3,674 |
$49K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
856 |
579 |
$40K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
936 |
936 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,808 |
1,806 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,075 |
3,071 |
$21K |
| D0274 |
Bitewings - four radiographic images |
723 |
723 |
$20K |
| D1110 |
Prophylaxis - adult |
364 |
364 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
264 |
202 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
226 |
223 |
$3K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
15 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$494.00 |
| D0603 |
|
1,224 |
1,224 |
$0.00 |
| D1330 |
|
23 |
23 |
$0.00 |