| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,027 |
3,026 |
$104K |
| D0120 |
Periodic oral evaluation - established patient |
3,986 |
3,985 |
$93K |
| D0274 |
Bitewings - four radiographic images |
3,520 |
3,520 |
$81K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,027 |
721 |
$57K |
| D0220 |
Intraoral - periapical first radiographic image |
3,918 |
3,917 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,610 |
3,609 |
$43K |
| D1110 |
Prophylaxis - adult |
929 |
929 |
$42K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
901 |
648 |
$35K |
| D1351 |
Sealant - per tooth |
1,000 |
330 |
$34K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
389 |
329 |
$30K |
| D7140 |
Extraction, erupted tooth or exposed root |
633 |
417 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,485 |
2,485 |
$13K |
| D1206 |
Topical application of fluoride varnish |
423 |
423 |
$9K |
| D9990 |
|
322 |
309 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
33 |
$724.80 |
| D9310 |
|
12 |
12 |
$641.28 |
| D0140 |
Limited oral evaluation - problem focused |
54 |
54 |
$564.82 |