| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,208 |
1,207 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
1,318 |
1,317 |
$34K |
| D0274 |
Bitewings - four radiographic images |
1,112 |
1,112 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
1,456 |
1,423 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,220 |
1,219 |
$16K |
| D1351 |
Sealant - per tooth |
372 |
124 |
$15K |
| D1110 |
Prophylaxis - adult |
126 |
126 |
$6K |
| D1206 |
Topical application of fluoride varnish |
185 |
185 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
591 |
587 |
$4K |
| D2394 |
|
18 |
13 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
20 |
15 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$695.50 |