| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
628 |
592 |
$22K |
| D1351 |
Sealant - per tooth |
473 |
159 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
541 |
514 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
272 |
253 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
137 |
108 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
73 |
62 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
60 |
37 |
$2K |
| D0272 |
Bitewings - two radiographic images |
221 |
200 |
$2K |
| D0274 |
Bitewings - four radiographic images |
90 |
90 |
$1K |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$670.85 |
| D0220 |
Intraoral - periapical first radiographic image |
76 |
75 |
$369.60 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
19 |
$291.60 |