| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,672 |
3,672 |
$151K |
| D0120 |
Periodic oral evaluation - established patient |
3,851 |
3,851 |
$107K |
| D1351 |
Sealant - per tooth |
2,147 |
651 |
$88K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,563 |
4,563 |
$61K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
957 |
522 |
$54K |
| D0272 |
Bitewings - two radiographic images |
2,851 |
2,851 |
$46K |
| D1110 |
Prophylaxis - adult |
810 |
810 |
$45K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,963 |
2,957 |
$41K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
309 |
113 |
$34K |
| D7140 |
Extraction, erupted tooth or exposed root |
565 |
324 |
$32K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
532 |
323 |
$22K |
| D0274 |
Bitewings - four radiographic images |
802 |
802 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,251 |
1,250 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
315 |
315 |
$9K |
| D1354 |
|
176 |
42 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
86 |
$2K |
| D0240 |
|
116 |
116 |
$2K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$1K |