| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,573 |
6,572 |
$271K |
| D0120 |
Periodic oral evaluation - established patient |
6,347 |
6,347 |
$211K |
| D1206 |
Topical application of fluoride varnish |
6,830 |
6,829 |
$187K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,213 |
830 |
$149K |
| D1351 |
Sealant - per tooth |
2,722 |
834 |
$85K |
| D0140 |
Limited oral evaluation - problem focused |
944 |
938 |
$59K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
611 |
461 |
$57K |
| D0272 |
Bitewings - two radiographic images |
2,264 |
2,264 |
$54K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
243 |
192 |
$46K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
570 |
569 |
$36K |
| D0220 |
Intraoral - periapical first radiographic image |
1,953 |
1,940 |
$36K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,488 |
1,011 |
$33K |
| D0330 |
Panoramic radiographic image |
230 |
230 |
$17K |
| D1110 |
Prophylaxis - adult |
258 |
258 |
$13K |
| D0240 |
|
553 |
290 |
$12K |
| D0274 |
Bitewings - four radiographic images |
349 |
349 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
107 |
71 |
$10K |
| D9248 |
|
164 |
162 |
$10K |
| D0210 |
Intraoral - complete series of radiographic images |
90 |
83 |
$5K |
| D0145 |
Oral evaluation for a patient under three years of age |
51 |
51 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
75 |
75 |
$2K |