| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,285 |
1,245 |
$34K |
| D0272 |
Bitewings - two radiographic images |
1,377 |
1,348 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,273 |
1,241 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
866 |
841 |
$19K |
| D1351 |
Sealant - per tooth |
747 |
361 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,395 |
1,359 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
430 |
425 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,479 |
1,294 |
$14K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
119 |
102 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
120 |
97 |
$7K |
| D2140 |
|
87 |
72 |
$5K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
20 |
16 |
$2K |