| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,274 |
2,274 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
2,230 |
2,230 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
789 |
513 |
$41K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,659 |
2,659 |
$31K |
| D1110 |
Prophylaxis - adult |
420 |
420 |
$20K |
| D1351 |
Sealant - per tooth |
517 |
198 |
$19K |
| D0272 |
Bitewings - two radiographic images |
1,074 |
1,074 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
965 |
962 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
417 |
417 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
255 |
185 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
719 |
719 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
91 |
65 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
195 |
154 |
$6K |
| D0274 |
Bitewings - four radiographic images |
142 |
142 |
$3K |
| D0330 |
Panoramic radiographic image |
46 |
46 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
103 |
103 |
$1K |
| D0145 |
Oral evaluation for a patient under three years of age |
37 |
37 |
$948.24 |
| D9990 |
|
39 |
39 |
$847.00 |
| D1206 |
Topical application of fluoride varnish |
30 |
30 |
$738.00 |