| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,675 |
3,675 |
$128K |
| D0120 |
Periodic oral evaluation - established patient |
3,822 |
3,822 |
$90K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,091 |
1,045 |
$72K |
| D1351 |
Sealant - per tooth |
786 |
718 |
$65K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,457 |
4,457 |
$51K |
| D1110 |
Prophylaxis - adult |
939 |
939 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
841 |
810 |
$36K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
395 |
385 |
$34K |
| D0272 |
Bitewings - two radiographic images |
2,042 |
2,042 |
$28K |
| D7140 |
Extraction, erupted tooth or exposed root |
640 |
618 |
$27K |
| D0220 |
Intraoral - periapical first radiographic image |
1,912 |
1,904 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
893 |
893 |
$21K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,326 |
1,322 |
$11K |
| D0274 |
Bitewings - four radiographic images |
363 |
363 |
$8K |
| D9990 |
|
354 |
348 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
510 |
498 |
$6K |
| D1206 |
Topical application of fluoride varnish |
119 |
119 |
$3K |
| D0330 |
Panoramic radiographic image |
71 |
71 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
12 |
12 |
$616.36 |