| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,164 |
1,130 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,173 |
1,136 |
$32K |
| D1351 |
Sealant - per tooth |
477 |
200 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,162 |
1,130 |
$30K |
| D0220 |
Intraoral - periapical first radiographic image |
1,037 |
1,011 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
84 |
66 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
101 |
80 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
76 |
59 |
$4K |
| D0272 |
Bitewings - two radiographic images |
164 |
159 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
242 |
241 |
$1K |