| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
392 |
392 |
$16K |
| D1206 |
Topical application of fluoride varnish |
464 |
464 |
$16K |
| D7140 |
Extraction, erupted tooth or exposed root |
353 |
248 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
691 |
680 |
$14K |
| D0274 |
Bitewings - four radiographic images |
422 |
410 |
$10K |
| D1110 |
Prophylaxis - adult |
134 |
134 |
$5K |
| D1351 |
Sealant - per tooth |
245 |
92 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
211 |
199 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
141 |
141 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
20 |
20 |
$600.00 |
| D9992 |
|
13 |
13 |
$260.00 |