| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,896 |
1,895 |
$70K |
| D0120 |
Periodic oral evaluation - established patient |
1,911 |
1,911 |
$48K |
| D1206 |
Topical application of fluoride varnish |
1,062 |
1,062 |
$26K |
| D0272 |
Bitewings - two radiographic images |
1,236 |
1,236 |
$17K |
| D1351 |
Sealant - per tooth |
472 |
151 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
960 |
960 |
$12K |
| D1110 |
Prophylaxis - adult |
174 |
174 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
760 |
758 |
$8K |
| D0274 |
Bitewings - four radiographic images |
291 |
291 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
111 |
111 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
468 |
468 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
28 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
15 |
12 |
$606.22 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$190.90 |