| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
982 |
843 |
$13K |
| D1999 |
|
592 |
471 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
906 |
782 |
$10K |
| D1120 |
Prophylaxis - child |
548 |
466 |
$9K |
| D0272 |
Bitewings - two radiographic images |
615 |
527 |
$8K |
| D0330 |
Panoramic radiographic image |
237 |
192 |
$6K |
| D1110 |
Prophylaxis - adult |
192 |
166 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
148 |
55 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
92 |
$2K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
38 |
27 |
$1K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
43 |
27 |
$1K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
20 |
14 |
$1K |
| D1351 |
Sealant - per tooth |
57 |
12 |
$756.90 |