| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1208 |
Topical application of fluoride, excluding varnish |
1,810 |
1,488 |
$25K |
| D1120 |
Prophylaxis - child |
1,446 |
1,184 |
$23K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
745 |
347 |
$18K |
| D7140 |
Extraction, erupted tooth or exposed root |
667 |
309 |
$15K |
| D1351 |
Sealant - per tooth |
1,122 |
165 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
1,375 |
1,101 |
$14K |
| D2140 |
|
556 |
236 |
$12K |
| D1110 |
Prophylaxis - adult |
331 |
262 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
457 |
403 |
$6K |
| D1999 |
|
199 |
170 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
47 |
28 |
$3K |
| D3120 |
|
142 |
70 |
$3K |
| D0330 |
Panoramic radiographic image |
87 |
77 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
594 |
251 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
205 |
167 |
$1K |
| D2160 |
|
32 |
28 |
$887.40 |
| D0272 |
Bitewings - two radiographic images |
44 |
35 |
$591.76 |