| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,624 |
2,593 |
$134K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
427 |
84 |
$87K |
| D1206 |
Topical application of fluoride varnish |
3,089 |
3,044 |
$81K |
| D0120 |
Periodic oral evaluation - established patient |
2,141 |
2,111 |
$63K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
813 |
800 |
$46K |
| D0272 |
Bitewings - two radiographic images |
1,408 |
1,388 |
$42K |
| D7140 |
Extraction, erupted tooth or exposed root |
235 |
68 |
$23K |
| D0140 |
Limited oral evaluation - problem focused |
412 |
408 |
$19K |
| D1351 |
Sealant - per tooth |
343 |
93 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
542 |
525 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
440 |
337 |
$7K |
| D0330 |
Panoramic radiographic image |
29 |
29 |
$3K |