| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,582 |
4,330 |
$193K |
| D1208 |
Topical application of fluoride, excluding varnish |
5,091 |
4,810 |
$140K |
| D0120 |
Periodic oral evaluation - established patient |
3,980 |
3,750 |
$81K |
| D1310 |
|
503 |
398 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
154 |
123 |
$16K |
| D1330 |
|
500 |
394 |
$15K |
| D1110 |
Prophylaxis - adult |
213 |
197 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
227 |
202 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
72 |
$6K |
| D1351 |
Sealant - per tooth |
173 |
36 |
$6K |
| D0272 |
Bitewings - two radiographic images |
217 |
192 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$780.00 |