| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,902 |
1,902 |
$63K |
| D0120 |
Periodic oral evaluation - established patient |
2,194 |
2,194 |
$50K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
836 |
518 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,562 |
1,562 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,016 |
2,016 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
2,053 |
2,049 |
$22K |
| D7140 |
Extraction, erupted tooth or exposed root |
557 |
356 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
509 |
329 |
$19K |
| D1110 |
Prophylaxis - adult |
421 |
421 |
$19K |
| D1351 |
Sealant - per tooth |
476 |
158 |
$17K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,477 |
1,476 |
$8K |
| D1206 |
Topical application of fluoride varnish |
367 |
366 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
74 |
53 |
$5K |
| D0272 |
Bitewings - two radiographic images |
304 |
304 |
$4K |
| D9990 |
|
60 |
59 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
20 |
$423.28 |