| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,619 |
1,504 |
$42K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
829 |
727 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,432 |
1,328 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
764 |
737 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
189 |
131 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
122 |
67 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
46 |
25 |
$6K |
| D0274 |
Bitewings - four radiographic images |
86 |
85 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
18 |
15 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
128 |
103 |
$1K |
| D0272 |
Bitewings - two radiographic images |
56 |
55 |
$1K |