| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,691 |
2,902 |
$73K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,018 |
1,712 |
$66K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
378 |
59 |
$49K |
| D1351 |
Sealant - per tooth |
1,820 |
388 |
$44K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,595 |
2,875 |
$41K |
| D7140 |
Extraction, erupted tooth or exposed root |
398 |
142 |
$31K |
| D0330 |
Panoramic radiographic image |
937 |
823 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
803 |
763 |
$30K |
| D0272 |
Bitewings - two radiographic images |
1,905 |
1,633 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
1,002 |
753 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
63 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
190 |
190 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
465 |
230 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
145 |
135 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
33 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
1,116 |
444 |
$4K |
| D8670 |
Periodic orthodontic treatment visit |
49 |
45 |
$4K |
| D0274 |
Bitewings - four radiographic images |
155 |
151 |
$3K |