| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
298 |
295 |
$6K |
| D1110 |
Prophylaxis - adult |
174 |
173 |
$5K |
| D1120 |
Prophylaxis - child |
97 |
97 |
$2K |
| D1206 |
Topical application of fluoride varnish |
124 |
124 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
31 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
39 |
13 |
$950.00 |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$893.00 |
| D0220 |
Intraoral - periapical first radiographic image |
122 |
115 |
$492.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
122 |
58 |
$440.00 |
| D0272 |
Bitewings - two radiographic images |
33 |
33 |
$299.00 |
| D0330 |
Panoramic radiographic image |
56 |
56 |
$252.00 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$242.00 |