| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,401 |
2,401 |
$98K |
| D0120 |
Periodic oral evaluation - established patient |
2,251 |
2,251 |
$62K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
347 |
199 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,701 |
2,701 |
$36K |
| D1351 |
Sealant - per tooth |
782 |
248 |
$32K |
| D0272 |
Bitewings - two radiographic images |
1,838 |
1,838 |
$30K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
500 |
310 |
$27K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,990 |
1,987 |
$24K |
| D1110 |
Prophylaxis - adult |
253 |
253 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
297 |
185 |
$12K |
| D7140 |
Extraction, erupted tooth or exposed root |
206 |
150 |
$12K |
| D0145 |
Oral evaluation for a patient under three years of age |
260 |
260 |
$7K |
| D0274 |
Bitewings - four radiographic images |
257 |
257 |
$7K |
| D0240 |
|
449 |
449 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
439 |
437 |
$5K |
| D0330 |
Panoramic radiographic image |
87 |
87 |
$3K |
| D1354 |
|
85 |
28 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
90 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
26 |
20 |
$2K |