| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,777 |
2,728 |
$113K |
| D0120 |
Periodic oral evaluation - established patient |
2,711 |
2,664 |
$75K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,739 |
1,717 |
$45K |
| D0274 |
Bitewings - four radiographic images |
386 |
379 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
857 |
823 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
734 |
711 |
$4K |
| D1351 |
Sealant - per tooth |
14 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
144 |
136 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$978.00 |
| D9110 |
|
12 |
12 |
$660.00 |
| D1999 |
|
20 |
18 |
$0.00 |