| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
5,591 |
5,279 |
$228K |
| D1351 |
Sealant - per tooth |
2,319 |
1,270 |
$165K |
| D0120 |
Periodic oral evaluation - established patient |
5,175 |
4,896 |
$145K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,596 |
5,285 |
$145K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,026 |
813 |
$76K |
| D0272 |
Bitewings - two radiographic images |
1,723 |
1,601 |
$17K |
| D0330 |
Panoramic radiographic image |
455 |
438 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
169 |
141 |
$9K |
| D0274 |
Bitewings - four radiographic images |
405 |
382 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
270 |
252 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
893 |
840 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
284 |
271 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
24 |
$1K |