| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
529 |
442 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
625 |
507 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
512 |
427 |
$13K |
| D0274 |
Bitewings - four radiographic images |
326 |
267 |
$5K |
| D1110 |
Prophylaxis - adult |
75 |
58 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
425 |
348 |
$2K |
| D1351 |
Sealant - per tooth |
14 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
405 |
314 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
46 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
17 |
13 |
$625.92 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$122.20 |
| D1999 |
|
238 |
205 |
$0.00 |