| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,252 |
4,970 |
$195K |
| D1351 |
Sealant - per tooth |
2,983 |
1,828 |
$138K |
| D0120 |
Periodic oral evaluation - established patient |
5,311 |
5,028 |
$137K |
| D1206 |
Topical application of fluoride varnish |
5,244 |
4,963 |
$118K |
| D7140 |
Extraction, erupted tooth or exposed root |
408 |
365 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
272 |
241 |
$14K |
| D0140 |
Limited oral evaluation - problem focused |
918 |
886 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
289 |
252 |
$10K |
| D0602 |
|
1,928 |
1,832 |
$8K |
| D0601 |
|
2,153 |
2,049 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
722 |
696 |
$4K |
| D0603 |
|
768 |
734 |
$3K |
| D2330 |
|
18 |
13 |
$761.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
78 |
77 |
$304.00 |