| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,602 |
3,128 |
$94K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
1,024 |
561 |
$81K |
| D2140 |
|
893 |
496 |
$52K |
| D0120 |
Periodic oral evaluation - established patient |
1,925 |
1,803 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,620 |
1,286 |
$44K |
| D0140 |
Limited oral evaluation - problem focused |
1,200 |
987 |
$39K |
| D1206 |
Topical application of fluoride varnish |
1,578 |
1,305 |
$33K |
| D7140 |
Extraction, erupted tooth or exposed root |
428 |
215 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,718 |
1,539 |
$26K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
121 |
25 |
$15K |
| D0274 |
Bitewings - four radiographic images |
506 |
417 |
$12K |
| D0330 |
Panoramic radiographic image |
235 |
193 |
$8K |
| D1351 |
Sealant - per tooth |
296 |
46 |
$8K |
| D0272 |
Bitewings - two radiographic images |
313 |
228 |
$4K |
| D9310 |
|
84 |
77 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
194 |
138 |
$2K |