| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,187 |
1,177 |
$46K |
| D1351 |
Sealant - per tooth |
586 |
296 |
$45K |
| D0120 |
Periodic oral evaluation - established patient |
1,324 |
1,316 |
$35K |
| D4341 |
|
199 |
83 |
$32K |
| D1206 |
Topical application of fluoride varnish |
642 |
640 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
691 |
679 |
$16K |
| D0274 |
Bitewings - four radiographic images |
822 |
813 |
$14K |
| D1110 |
Prophylaxis - adult |
292 |
291 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
501 |
493 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
166 |
126 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
198 |
127 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,509 |
1,481 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
306 |
300 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,336 |
1,289 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
192 |
187 |
$4K |
| D0272 |
Bitewings - two radiographic images |
295 |
294 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
29 |
$1K |