| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,430 |
2,284 |
$95K |
| D0120 |
Periodic oral evaluation - established patient |
2,928 |
2,760 |
$75K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,408 |
2,263 |
$59K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
919 |
497 |
$51K |
| D1351 |
Sealant - per tooth |
992 |
395 |
$44K |
| D1110 |
Prophylaxis - adult |
734 |
681 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,275 |
1,181 |
$21K |
| D7140 |
Extraction, erupted tooth or exposed root |
209 |
119 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
511 |
476 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,445 |
1,356 |
$8K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
123 |
70 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,213 |
1,040 |
$5K |
| D0272 |
Bitewings - two radiographic images |
539 |
506 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
125 |
100 |
$4K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
35 |
12 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
50 |
47 |
$793.80 |