| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,390 |
2,733 |
$194K |
| D0999 |
Unspecified diagnostic procedure, by report |
924 |
741 |
$105K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
545 |
501 |
$43K |
| D0120 |
Periodic oral evaluation - established patient |
2,822 |
1,468 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
140 |
138 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
27 |
27 |
$4K |
| D1206 |
Topical application of fluoride varnish |
2,850 |
1,411 |
$116.92 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
1,044 |
565 |
$0.00 |