| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,718 |
1,718 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
1,776 |
1,776 |
$49K |
| D1351 |
Sealant - per tooth |
979 |
297 |
$42K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,081 |
2,081 |
$28K |
| D0272 |
Bitewings - two radiographic images |
1,276 |
1,276 |
$20K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,047 |
1,029 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
987 |
985 |
$14K |
| D1110 |
Prophylaxis - adult |
202 |
202 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
75 |
$9K |
| D7140 |
Extraction, erupted tooth or exposed root |
141 |
86 |
$8K |
| D1354 |
|
189 |
40 |
$8K |
| D0274 |
Bitewings - four radiographic images |
207 |
207 |
$6K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$733.50 |
| D0240 |
|
16 |
16 |
$258.40 |