| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,953 |
2,945 |
$122K |
| D0120 |
Periodic oral evaluation - established patient |
2,835 |
2,831 |
$81K |
| D1206 |
Topical application of fluoride varnish |
2,878 |
2,871 |
$76K |
| D1351 |
Sealant - per tooth |
564 |
340 |
$54K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
582 |
526 |
$40K |
| D0274 |
Bitewings - four radiographic images |
1,177 |
1,174 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
2,302 |
2,288 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
528 |
525 |
$13K |
| D1110 |
Prophylaxis - adult |
229 |
229 |
$11K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
262 |
250 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,101 |
2,075 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
131 |
107 |
$9K |
| D0272 |
Bitewings - two radiographic images |
714 |
712 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
260 |
260 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
13 |
12 |
$963.05 |