| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,381 |
4,379 |
$217K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,602 |
810 |
$156K |
| D0120 |
Periodic oral evaluation - established patient |
3,740 |
3,740 |
$125K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
920 |
214 |
$122K |
| D1206 |
Topical application of fluoride varnish |
3,102 |
3,101 |
$86K |
| D1351 |
Sealant - per tooth |
1,159 |
514 |
$55K |
| D0272 |
Bitewings - two radiographic images |
1,984 |
1,983 |
$37K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
867 |
867 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,507 |
1,507 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
375 |
152 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
251 |
163 |
$16K |
| D0330 |
Panoramic radiographic image |
302 |
302 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
764 |
755 |
$11K |
| D1110 |
Prophylaxis - adult |
121 |
121 |
$8K |
| D0240 |
|
294 |
270 |
$7K |
| D0274 |
Bitewings - four radiographic images |
179 |
179 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
146 |
129 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
25 |
25 |
$386.40 |