| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,117 |
4,888 |
$210K |
| D1351 |
Sealant - per tooth |
2,869 |
1,538 |
$208K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,591 |
4,387 |
$119K |
| D0120 |
Periodic oral evaluation - established patient |
3,132 |
3,023 |
$88K |
| D1354 |
|
1,810 |
1,285 |
$60K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,008 |
1,876 |
$46K |
| D0274 |
Bitewings - four radiographic images |
700 |
661 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,073 |
804 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
158 |
81 |
$9K |
| D0272 |
Bitewings - two radiographic images |
774 |
761 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
1,392 |
1,294 |
$8K |
| D1206 |
Topical application of fluoride varnish |
139 |
139 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
40 |
27 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$986.85 |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$97.50 |