| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
985 |
985 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
982 |
982 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,193 |
1,193 |
$16K |
| D1351 |
Sealant - per tooth |
351 |
103 |
$15K |
| D0272 |
Bitewings - two radiographic images |
725 |
725 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
756 |
756 |
$12K |
| D1110 |
Prophylaxis - adult |
76 |
76 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
61 |
36 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
267 |
265 |
$3K |
| D0274 |
Bitewings - four radiographic images |
76 |
76 |
$2K |
| D0145 |
Oral evaluation for a patient under three years of age |
54 |
54 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
13 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$844.00 |