| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,028 |
4,028 |
$115K |
| D1120 |
Prophylaxis - child |
2,625 |
2,625 |
$113K |
| D1110 |
Prophylaxis - adult |
1,193 |
1,193 |
$67K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,006 |
4,006 |
$57K |
| D1351 |
Sealant - per tooth |
445 |
111 |
$19K |
| D0274 |
Bitewings - four radiographic images |
649 |
649 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,025 |
1,025 |
$17K |
| D7140 |
Extraction, erupted tooth or exposed root |
127 |
64 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
53 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
258 |
257 |
$3K |
| D0330 |
Panoramic radiographic image |
19 |
19 |
$755.00 |