| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
5,710 |
1,412 |
$80K |
| D1120 |
Prophylaxis - child |
1,715 |
1,715 |
$74K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
715 |
715 |
$44K |
| D1206 |
Topical application of fluoride varnish |
1,479 |
1,479 |
$44K |
| D0220 |
Intraoral - periapical first radiographic image |
1,455 |
1,455 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
514 |
514 |
$18K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
64 |
17 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
201 |
201 |
$6K |
| D1351 |
Sealant - per tooth |
106 |
29 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
16 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
67 |
67 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
14 |
$3K |
| D9310 |
|
27 |
27 |
$2K |
| D0272 |
Bitewings - two radiographic images |
67 |
67 |
$2K |