| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
6,602 |
6,097 |
$151K |
| D1351 |
Sealant - per tooth |
8,683 |
2,765 |
$144K |
| D1206 |
Topical application of fluoride varnish |
5,797 |
5,277 |
$66K |
| D0191 |
|
5,753 |
5,333 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,105 |
3,921 |
$50K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,403 |
1,230 |
$29K |
| D1110 |
Prophylaxis - adult |
461 |
437 |
$13K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
142 |
68 |
$11K |
| D0272 |
Bitewings - two radiographic images |
280 |
252 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
168 |
149 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
175 |
150 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
68 |
57 |
$1K |
| D7111 |
|
20 |
13 |
$1K |
| D0240 |
|
34 |
12 |
$323.39 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$220.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
33 |
14 |
$76.10 |