| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,318 |
2,282 |
$177K |
| D1120 |
Prophylaxis - child |
2,513 |
2,465 |
$64K |
| D1206 |
Topical application of fluoride varnish |
2,780 |
2,725 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,248 |
1,219 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,149 |
1,092 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
227 |
214 |
$10K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
126 |
32 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
992 |
744 |
$6K |
| D1351 |
Sealant - per tooth |
152 |
39 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
34 |
14 |
$3K |
| D0274 |
Bitewings - four radiographic images |
142 |
142 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
54 |
45 |
$1K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$632.59 |