| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,526 |
1,524 |
$62K |
| D1206 |
Topical application of fluoride varnish |
1,759 |
1,756 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,325 |
1,324 |
$42K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
338 |
226 |
$40K |
| D7140 |
Extraction, erupted tooth or exposed root |
295 |
118 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
221 |
147 |
$20K |
| D0272 |
Bitewings - two radiographic images |
620 |
620 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
184 |
182 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
43 |
12 |
$9K |
| D1110 |
Prophylaxis - adult |
172 |
172 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
145 |
145 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
264 |
261 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
255 |
95 |
$3K |
| D1351 |
Sealant - per tooth |
63 |
24 |
$2K |
| D0330 |
Panoramic radiographic image |
24 |
24 |
$2K |
| D0274 |
Bitewings - four radiographic images |
35 |
35 |
$1K |