| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,262 |
2,966 |
$128K |
| D1351 |
Sealant - per tooth |
1,440 |
705 |
$97K |
| D0120 |
Periodic oral evaluation - established patient |
2,987 |
2,691 |
$80K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,213 |
2,909 |
$80K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
407 |
307 |
$24K |
| D0274 |
Bitewings - four radiographic images |
1,684 |
1,478 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
3,596 |
3,124 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,465 |
3,008 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
137 |
109 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
200 |
$5K |
| D0272 |
Bitewings - two radiographic images |
480 |
429 |
$4K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
56 |
45 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
50 |
38 |
$3K |