| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,902 |
3,892 |
$159K |
| D1351 |
Sealant - per tooth |
2,110 |
1,017 |
$129K |
| D0120 |
Periodic oral evaluation - established patient |
3,751 |
3,734 |
$108K |
| D1206 |
Topical application of fluoride varnish |
3,902 |
3,892 |
$101K |
| D1354 |
|
2,466 |
1,375 |
$58K |
| D0140 |
Limited oral evaluation - problem focused |
1,402 |
1,398 |
$25K |
| D0601 |
|
1,608 |
1,603 |
$11K |
| D7140 |
Extraction, erupted tooth or exposed root |
188 |
165 |
$11K |
| D0602 |
|
1,353 |
1,348 |
$10K |
| D0603 |
|
802 |
802 |
$6K |
| D2140 |
|
84 |
73 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
379 |
379 |
$2K |
| D0274 |
Bitewings - four radiographic images |
122 |
122 |
$2K |
| D0272 |
Bitewings - two radiographic images |
126 |
126 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
71 |
68 |
$564.48 |
| D9630 |
|
53 |
53 |
$493.50 |