| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,131 |
4,131 |
$176K |
| D0120 |
Periodic oral evaluation - established patient |
3,215 |
3,215 |
$83K |
| D1206 |
Topical application of fluoride varnish |
2,542 |
2,542 |
$75K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
343 |
183 |
$34K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
894 |
894 |
$27K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
191 |
80 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,602 |
1,602 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,253 |
1,253 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
277 |
197 |
$18K |
| D0145 |
Oral evaluation for a patient under three years of age |
525 |
525 |
$16K |
| D1110 |
Prophylaxis - adult |
237 |
237 |
$12K |
| D1351 |
Sealant - per tooth |
179 |
71 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
111 |
88 |
$8K |
| D0240 |
|
236 |
184 |
$5K |
| D9920 |
|
114 |
114 |
$3K |
| D7961 |
|
15 |
15 |
$3K |
| D7962 |
|
14 |
14 |
$3K |
| D0330 |
Panoramic radiographic image |
78 |
78 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
69 |
69 |
$943.00 |
| D0274 |
Bitewings - four radiographic images |
22 |
22 |
$595.20 |
| D0220 |
Intraoral - periapical first radiographic image |
26 |
25 |
$329.68 |