| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,795 |
1,793 |
$76K |
| D0120 |
Periodic oral evaluation - established patient |
1,997 |
1,997 |
$58K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,773 |
1,771 |
$48K |
| D1351 |
Sealant - per tooth |
455 |
285 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
291 |
232 |
$21K |
| D0274 |
Bitewings - four radiographic images |
985 |
984 |
$19K |
| D1110 |
Prophylaxis - adult |
399 |
399 |
$19K |
| D0220 |
Intraoral - periapical first radiographic image |
2,452 |
2,434 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
284 |
239 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
535 |
531 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,308 |
2,295 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
96 |
87 |
$6K |
| D0272 |
Bitewings - two radiographic images |
434 |
432 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
235 |
228 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$158.05 |