| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,440 |
1,361 |
$54K |
| D0120 |
Periodic oral evaluation - established patient |
1,384 |
1,318 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,426 |
1,348 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
389 |
246 |
$27K |
| D0272 |
Bitewings - two radiographic images |
428 |
398 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
34 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
21 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
24 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
25 |
$140.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$79.80 |