| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
769 |
725 |
$31K |
| D0120 |
Periodic oral evaluation - established patient |
763 |
709 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
753 |
710 |
$19K |
| D7140 |
Extraction, erupted tooth or exposed root |
192 |
97 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
124 |
85 |
$6K |
| D1351 |
Sealant - per tooth |
120 |
60 |
$6K |
| D0274 |
Bitewings - four radiographic images |
360 |
334 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
272 |
258 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
96 |
67 |
$3K |
| D1110 |
Prophylaxis - adult |
129 |
118 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
174 |
162 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
420 |
378 |
$2K |
| D0272 |
Bitewings - two radiographic images |
216 |
209 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
164 |
152 |
$1K |