| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
429 |
423 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
420 |
415 |
$11K |
| D1206 |
Topical application of fluoride varnish |
377 |
371 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
125 |
125 |
$2K |
| D1351 |
Sealant - per tooth |
52 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
277 |
273 |
$2K |
| D0274 |
Bitewings - four radiographic images |
70 |
70 |
$1K |
| D0272 |
Bitewings - two radiographic images |
113 |
113 |
$1K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
237 |
236 |
$893.00 |
| D7140 |
Extraction, erupted tooth or exposed root |
16 |
12 |
$665.04 |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$511.70 |
| D0140 |
Limited oral evaluation - problem focused |
38 |
34 |
$469.80 |