| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,966 |
4,938 |
$163K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,120 |
263 |
$136K |
| D0120 |
Periodic oral evaluation - established patient |
4,467 |
4,428 |
$113K |
| D1206 |
Topical application of fluoride varnish |
2,561 |
2,556 |
$61K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,818 |
2,784 |
$51K |
| D0145 |
Oral evaluation for a patient under three years of age |
841 |
839 |
$36K |
| D0272 |
Bitewings - two radiographic images |
2,027 |
1,987 |
$33K |
| D0220 |
Intraoral - periapical first radiographic image |
2,595 |
2,532 |
$30K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,971 |
2,362 |
$25K |
| D1110 |
Prophylaxis - adult |
500 |
491 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
258 |
112 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
153 |
153 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
447 |
425 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
84 |
60 |
$6K |
| D0210 |
Intraoral - complete series of radiographic images |
53 |
51 |
$3K |
| D9420 |
|
24 |
24 |
$3K |
| D1351 |
Sealant - per tooth |
24 |
16 |
$711.22 |