| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
15,446 |
15,444 |
$535K |
| D0120 |
Periodic oral evaluation - established patient |
12,997 |
12,994 |
$299K |
| D1351 |
Sealant - per tooth |
7,430 |
2,201 |
$294K |
| D1208 |
Topical application of fluoride, excluding varnish |
12,809 |
12,807 |
$150K |
| D1206 |
Topical application of fluoride varnish |
4,902 |
4,900 |
$133K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
2,156 |
1,508 |
$131K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,106 |
5,106 |
$117K |
| D0220 |
Intraoral - periapical first radiographic image |
10,321 |
10,298 |
$106K |
| D0272 |
Bitewings - two radiographic images |
7,048 |
7,048 |
$92K |
| D1110 |
Prophylaxis - adult |
2,047 |
2,047 |
$88K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,008 |
1,537 |
$80K |
| D0230 |
Intraoral - periapical each additional radiographic image |
10,188 |
10,067 |
$58K |
| D0274 |
Bitewings - four radiographic images |
1,955 |
1,955 |
$43K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
162 |
142 |
$14K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
147 |
130 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
150 |
129 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
96 |
96 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
27 |
24 |
$2K |
| D1320 |
|
193 |
193 |
$2K |
| D1354 |
|
100 |
42 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
40 |
$462.48 |
| D0602 |
|
68 |
68 |
$68.00 |
| D0603 |
|
12 |
12 |
$12.00 |