| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
643 |
597 |
$31K |
| D1120 |
Prophylaxis - child |
559 |
522 |
$28K |
| D0140 |
Limited oral evaluation - problem focused |
772 |
710 |
$23K |
| D0274 |
Bitewings - four radiographic images |
868 |
795 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
672 |
611 |
$10K |
| D7140 |
Extraction, erupted tooth or exposed root |
190 |
48 |
$7K |
| D0330 |
Panoramic radiographic image |
134 |
123 |
$4K |
| D1351 |
Sealant - per tooth |
133 |
26 |
$3K |
| D9310 |
|
44 |
41 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
415 |
346 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
55 |
54 |
$2K |
| D9994 |
|
164 |
150 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$432.12 |