| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,156 |
1,156 |
$47K |
| D1354 |
|
1,101 |
191 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,471 |
1,470 |
$41K |
| D2394 |
|
256 |
145 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,190 |
1,190 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,470 |
1,470 |
$19K |
| D1110 |
Prophylaxis - adult |
310 |
310 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
737 |
731 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
705 |
705 |
$13K |
| D1351 |
Sealant - per tooth |
277 |
92 |
$11K |
| D2335 |
|
56 |
37 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
89 |
73 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
69 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
97 |
66 |
$6K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
17 |
14 |
$1K |