| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,338 |
2,309 |
$96K |
| D0120 |
Periodic oral evaluation - established patient |
2,467 |
2,431 |
$69K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
463 |
378 |
$38K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,192 |
1,178 |
$31K |
| D1351 |
Sealant - per tooth |
196 |
128 |
$23K |
| D0274 |
Bitewings - four radiographic images |
478 |
478 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
84 |
59 |
$4K |
| D0272 |
Bitewings - two radiographic images |
84 |
84 |
$885.93 |