| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
668 |
668 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
800 |
800 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
781 |
781 |
$10K |
| D0272 |
Bitewings - two radiographic images |
314 |
314 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
405 |
399 |
$5K |
| D7140 |
Extraction, erupted tooth or exposed root |
39 |
34 |
$3K |
| D1110 |
Prophylaxis - adult |
34 |
34 |
$2K |
| D1351 |
Sealant - per tooth |
30 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
67 |
67 |
$389.59 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$371.50 |