| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,612 |
4,610 |
$153K |
| D0120 |
Periodic oral evaluation - established patient |
3,369 |
3,367 |
$76K |
| D1206 |
Topical application of fluoride varnish |
2,358 |
2,358 |
$55K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,468 |
1,468 |
$33K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
458 |
400 |
$31K |
| D0272 |
Bitewings - two radiographic images |
2,087 |
2,087 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,364 |
2,364 |
$27K |
| D1351 |
Sealant - per tooth |
265 |
213 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
187 |
168 |
$7K |
| D0240 |
|
184 |
182 |
$4K |
| D1110 |
Prophylaxis - adult |
58 |
58 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
48 |
38 |
$2K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
12 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
104 |
104 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$761.12 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$181.82 |