| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,392 |
4,388 |
$195K |
| D0120 |
Periodic oral evaluation - established patient |
4,365 |
4,361 |
$154K |
| D1206 |
Topical application of fluoride varnish |
4,888 |
4,884 |
$145K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,096 |
578 |
$142K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
417 |
197 |
$81K |
| D0272 |
Bitewings - two radiographic images |
1,929 |
1,927 |
$47K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
378 |
281 |
$37K |
| D1110 |
Prophylaxis - adult |
479 |
479 |
$25K |
| D0330 |
Panoramic radiographic image |
119 |
119 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
471 |
457 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
123 |
123 |
$7K |
| D0274 |
Bitewings - four radiographic images |
80 |
80 |
$3K |
| D0240 |
|
119 |
59 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$1K |