| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,232 |
1,182 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,165 |
1,087 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
507 |
362 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
926 |
891 |
$24K |
| D0274 |
Bitewings - four radiographic images |
655 |
591 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
433 |
405 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
1,428 |
1,320 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
168 |
146 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,332 |
1,235 |
$5K |
| D0272 |
Bitewings - two radiographic images |
415 |
397 |
$4K |
| D1351 |
Sealant - per tooth |
31 |
28 |
$3K |
| D1110 |
Prophylaxis - adult |
59 |
51 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$586.80 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$382.20 |
| D0140 |
Limited oral evaluation - problem focused |
14 |
12 |
$194.40 |