| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,228 |
953 |
$26K |
| D1351 |
Sealant - per tooth |
957 |
159 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
465 |
414 |
$14K |
| D1206 |
Topical application of fluoride varnish |
759 |
593 |
$12K |
| D0274 |
Bitewings - four radiographic images |
385 |
302 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
253 |
210 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
400 |
269 |
$7K |
| D7140 |
Extraction, erupted tooth or exposed root |
55 |
39 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
74 |
61 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$473.61 |