| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,620 |
1,445 |
$66K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,598 |
1,434 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
1,405 |
1,253 |
$39K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
512 |
359 |
$34K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,534 |
1,364 |
$9K |
| D0274 |
Bitewings - four radiographic images |
832 |
769 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,561 |
1,382 |
$9K |
| D1351 |
Sealant - per tooth |
80 |
55 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
136 |
98 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
116 |
93 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
19 |
12 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$782.40 |