| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,450 |
1,450 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,559 |
1,559 |
$49K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
255 |
114 |
$46K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
259 |
164 |
$31K |
| D7140 |
Extraction, erupted tooth or exposed root |
322 |
186 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
831 |
831 |
$22K |
| D1110 |
Prophylaxis - adult |
393 |
393 |
$20K |
| D1206 |
Topical application of fluoride varnish |
785 |
784 |
$20K |
| D1351 |
Sealant - per tooth |
580 |
163 |
$18K |
| D0272 |
Bitewings - two radiographic images |
564 |
564 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
692 |
687 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
180 |
180 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
762 |
385 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
95 |
75 |
$9K |
| D0274 |
Bitewings - four radiographic images |
190 |
190 |
$8K |
| D0330 |
Panoramic radiographic image |
99 |
99 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
94 |
93 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
55 |
55 |
$5K |
| D9310 |
|
52 |
52 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
29 |
16 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
42 |
42 |
$2K |
| D1354 |
|
34 |
15 |
$1K |