| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
278 |
278 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
276 |
276 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
260 |
260 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
251 |
251 |
$6K |
| D1110 |
Prophylaxis - adult |
125 |
125 |
$6K |
| D0274 |
Bitewings - four radiographic images |
297 |
297 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
84 |
69 |
$5K |
| D1351 |
Sealant - per tooth |
30 |
17 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
377 |
377 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
397 |
337 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
25 |
$1K |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$687.58 |