| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,126 |
1,126 |
$48K |
| D1351 |
Sealant - per tooth |
444 |
272 |
$39K |
| D0120 |
Periodic oral evaluation - established patient |
1,194 |
1,194 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,016 |
1,016 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
279 |
250 |
$20K |
| D0274 |
Bitewings - four radiographic images |
916 |
916 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,676 |
1,667 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
363 |
363 |
$9K |
| D1110 |
Prophylaxis - adult |
171 |
171 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,390 |
1,390 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
259 |
256 |
$5K |
| D0272 |
Bitewings - two radiographic images |
290 |
290 |
$3K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
26 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
13 |
13 |
$354.90 |