| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,746 |
1,745 |
$69K |
| D0120 |
Periodic oral evaluation - established patient |
2,249 |
2,247 |
$59K |
| D1351 |
Sealant - per tooth |
798 |
214 |
$32K |
| D1206 |
Topical application of fluoride varnish |
957 |
957 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
368 |
223 |
$25K |
| D7140 |
Extraction, erupted tooth or exposed root |
419 |
276 |
$24K |
| D0274 |
Bitewings - four radiographic images |
868 |
868 |
$22K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,577 |
1,574 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
972 |
972 |
$13K |
| D0272 |
Bitewings - two radiographic images |
712 |
712 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
742 |
738 |
$8K |
| D1110 |
Prophylaxis - adult |
25 |
25 |
$1K |