| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
13,908 |
13,906 |
$598K |
| D0120 |
Periodic oral evaluation - established patient |
18,572 |
18,570 |
$464K |
| D1351 |
Sealant - per tooth |
7,269 |
2,087 |
$259K |
| D1208 |
Topical application of fluoride, excluding varnish |
18,297 |
18,295 |
$256K |
| D1110 |
Prophylaxis - adult |
4,517 |
4,517 |
$203K |
| D7140 |
Extraction, erupted tooth or exposed root |
2,627 |
1,998 |
$132K |
| D0272 |
Bitewings - two radiographic images |
6,848 |
6,846 |
$95K |
| D0220 |
Intraoral - periapical first radiographic image |
10,257 |
10,160 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,260 |
733 |
$80K |
| D0330 |
Panoramic radiographic image |
2,284 |
2,284 |
$79K |
| D0274 |
Bitewings - four radiographic images |
1,709 |
1,709 |
$41K |
| D0230 |
Intraoral - periapical each additional radiographic image |
5,707 |
5,704 |
$29K |
| D0140 |
Limited oral evaluation - problem focused |
1,108 |
1,106 |
$15K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
116 |
88 |
$13K |
| D1206 |
Topical application of fluoride varnish |
223 |
223 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
112 |
88 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
31 |
28 |
$3K |
| D0601 |
|
2,084 |
2,084 |
$2K |
| D0602 |
|
636 |
636 |
$634.00 |
| D9310 |
|
12 |
12 |
$360.00 |
| D0603 |
|
217 |
217 |
$217.00 |
| D0270 |
|
12 |
12 |
$96.00 |