| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,477 |
4,176 |
$189K |
| D1206 |
Topical application of fluoride varnish |
5,242 |
4,855 |
$142K |
| D0120 |
Periodic oral evaluation - established patient |
4,369 |
4,076 |
$129K |
| D1351 |
Sealant - per tooth |
1,643 |
547 |
$61K |
| D0274 |
Bitewings - four radiographic images |
792 |
730 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
612 |
565 |
$14K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
144 |
123 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
280 |
249 |
$13K |
| D0272 |
Bitewings - two radiographic images |
1,100 |
1,021 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
188 |
143 |
$9K |
| D0330 |
Panoramic radiographic image |
341 |
314 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,130 |
1,017 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
170 |
140 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
90 |
74 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
185 |
142 |
$1K |
| D1999 |
|
115 |
115 |
$0.00 |
| D0190 |
|
114 |
114 |
$0.00 |
| D0602 |
|
562 |
453 |
$0.00 |
| D0601 |
|
640 |
525 |
$0.00 |
| D0603 |
|
281 |
231 |
$0.00 |