| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
404 |
310 |
$20K |
| D1206 |
Topical application of fluoride varnish |
394 |
301 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
248 |
191 |
$6K |
| D7140 |
Extraction, erupted tooth or exposed root |
126 |
25 |
$6K |
| D0272 |
Bitewings - two radiographic images |
77 |
66 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
44 |
31 |
$2K |
| D1351 |
Sealant - per tooth |
47 |
13 |
$1K |
| D9920 |
|
15 |
15 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$488.25 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$365.04 |