| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,852 |
2,843 |
$79K |
| D1120 |
Prophylaxis - child |
1,784 |
1,775 |
$72K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,218 |
2,209 |
$55K |
| D1110 |
Prophylaxis - adult |
653 |
653 |
$35K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
225 |
161 |
$35K |
| D0220 |
Intraoral - periapical first radiographic image |
1,448 |
1,424 |
$24K |
| D0274 |
Bitewings - four radiographic images |
501 |
498 |
$18K |
| D2394 |
|
83 |
59 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,481 |
1,047 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
40 |
$6K |
| D0272 |
Bitewings - two radiographic images |
251 |
245 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
13 |
$1K |