| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,717 |
2,717 |
$137K |
| D0120 |
Periodic oral evaluation - established patient |
2,577 |
2,577 |
$88K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
601 |
366 |
$62K |
| D0220 |
Intraoral - periapical first radiographic image |
2,729 |
2,713 |
$50K |
| D0272 |
Bitewings - two radiographic images |
1,935 |
1,935 |
$47K |
| D1206 |
Topical application of fluoride varnish |
1,243 |
1,243 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,851 |
1,850 |
$34K |
| D1351 |
Sealant - per tooth |
585 |
182 |
$28K |
| D1110 |
Prophylaxis - adult |
416 |
416 |
$27K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
370 |
239 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
545 |
545 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,526 |
2,522 |
$20K |
| D7140 |
Extraction, erupted tooth or exposed root |
216 |
161 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
310 |
310 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
256 |
253 |
$3K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
15 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$1K |