| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,418 |
4,165 |
$171K |
| D0120 |
Periodic oral evaluation - established patient |
3,976 |
3,759 |
$108K |
| D1206 |
Topical application of fluoride varnish |
2,704 |
2,499 |
$67K |
| D7140 |
Extraction, erupted tooth or exposed root |
918 |
336 |
$49K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
380 |
242 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
710 |
675 |
$15K |
| D0272 |
Bitewings - two radiographic images |
1,118 |
1,023 |
$11K |
| D1351 |
Sealant - per tooth |
236 |
120 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
406 |
389 |
$9K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
128 |
26 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
85 |
53 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
120 |
113 |
$2K |
| D1354 |
|
87 |
56 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
331 |
273 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
39 |
26 |
$300.20 |