| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
615 |
597 |
$24K |
| D7140 |
Extraction, erupted tooth or exposed root |
308 |
214 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
761 |
738 |
$20K |
| D1351 |
Sealant - per tooth |
239 |
154 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
608 |
590 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
186 |
141 |
$14K |
| D1110 |
Prophylaxis - adult |
350 |
341 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
216 |
173 |
$13K |
| D0274 |
Bitewings - four radiographic images |
520 |
507 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
408 |
393 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
88 |
67 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
627 |
599 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
398 |
362 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
157 |
150 |
$2K |
| D0272 |
Bitewings - two radiographic images |
204 |
195 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
100 |
98 |
$1K |