| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,374 |
1,329 |
$68K |
| D0120 |
Periodic oral evaluation - established patient |
1,616 |
1,577 |
$43K |
| D1206 |
Topical application of fluoride varnish |
1,473 |
1,431 |
$38K |
| D1110 |
Prophylaxis - adult |
682 |
659 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
266 |
91 |
$27K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
184 |
29 |
$24K |
| D0272 |
Bitewings - two radiographic images |
532 |
493 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
176 |
160 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
372 |
340 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
94 |
89 |
$4K |
| D1351 |
Sealant - per tooth |
97 |
29 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
55 |
12 |
$3K |
| D9248 |
|
64 |
56 |
$3K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
27 |
13 |
$3K |
| D0274 |
Bitewings - four radiographic images |
68 |
66 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$1K |