| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,762 |
2,761 |
$110K |
| D0120 |
Periodic oral evaluation - established patient |
2,657 |
2,656 |
$87K |
| D1206 |
Topical application of fluoride varnish |
2,669 |
2,669 |
$73K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
513 |
342 |
$63K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
210 |
151 |
$37K |
| D1351 |
Sealant - per tooth |
1,073 |
310 |
$33K |
| D0272 |
Bitewings - two radiographic images |
842 |
842 |
$21K |
| D0220 |
Intraoral - periapical first radiographic image |
725 |
713 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
205 |
202 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
129 |
97 |
$12K |
| D0210 |
Intraoral - complete series of radiographic images |
140 |
140 |
$12K |
| D0330 |
Panoramic radiographic image |
147 |
147 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
651 |
278 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
122 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
77 |
54 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
177 |
177 |
$5K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
36 |
30 |
$4K |
| D0240 |
|
183 |
95 |
$4K |
| D9248 |
|
83 |
79 |
$4K |
| D1110 |
Prophylaxis - adult |
62 |
62 |
$3K |
| D0274 |
Bitewings - four radiographic images |
30 |
30 |
$1K |