| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,478 |
2,464 |
$74K |
| D0120 |
Periodic oral evaluation - established patient |
3,018 |
2,994 |
$60K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,984 |
2,960 |
$54K |
| D7140 |
Extraction, erupted tooth or exposed root |
488 |
251 |
$32K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
279 |
172 |
$27K |
| D9248 |
|
136 |
135 |
$25K |
| D1110 |
Prophylaxis - adult |
680 |
678 |
$24K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
366 |
204 |
$20K |
| D0330 |
Panoramic radiographic image |
469 |
467 |
$17K |
| D0272 |
Bitewings - two radiographic images |
929 |
922 |
$15K |
| D1351 |
Sealant - per tooth |
405 |
123 |
$10K |
| D0274 |
Bitewings - four radiographic images |
258 |
254 |
$7K |
| D0601 |
|
403 |
401 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
172 |
172 |
$3K |
| D1330 |
|
481 |
479 |
$2K |
| D0240 |
|
137 |
81 |
$2K |
| D9110 |
|
53 |
53 |
$2K |
| D0602 |
|
13 |
13 |
$130.00 |