| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,497 |
5,496 |
$263K |
| D1206 |
Topical application of fluoride varnish |
3,270 |
3,270 |
$109K |
| D0120 |
Periodic oral evaluation - established patient |
2,971 |
2,971 |
$96K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
427 |
318 |
$58K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
255 |
76 |
$46K |
| D7140 |
Extraction, erupted tooth or exposed root |
502 |
284 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,031 |
2,031 |
$32K |
| D0274 |
Bitewings - four radiographic images |
781 |
781 |
$27K |
| D1351 |
Sealant - per tooth |
364 |
205 |
$24K |
| D0272 |
Bitewings - two radiographic images |
1,193 |
1,193 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
672 |
672 |
$23K |
| D1354 |
|
755 |
287 |
$17K |
| D0240 |
|
479 |
418 |
$15K |
| D0330 |
Panoramic radiographic image |
217 |
217 |
$10K |
| D9420 |
|
13 |
13 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
18 |
18 |
$621.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$193.20 |
| D1999 |
|
157 |
154 |
$0.00 |
| D0602 |
|
14 |
14 |
$0.00 |