| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
474 |
467 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
575 |
561 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
658 |
645 |
$13K |
| D7140 |
Extraction, erupted tooth or exposed root |
272 |
136 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
356 |
352 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
513 |
505 |
$3K |
| D1351 |
Sealant - per tooth |
36 |
13 |
$2K |
| D1206 |
Topical application of fluoride varnish |
16 |
16 |
$416.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
53 |
$296.40 |