| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
606 |
602 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
555 |
549 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
517 |
513 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
554 |
548 |
$4K |
| D0274 |
Bitewings - four radiographic images |
135 |
135 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
496 |
485 |
$2K |
| D1351 |
Sealant - per tooth |
30 |
16 |
$2K |
| D1206 |
Topical application of fluoride varnish |
54 |
54 |
$1K |
| D0272 |
Bitewings - two radiographic images |
56 |
56 |
$554.50 |
| D0270 |
|
31 |
31 |
$151.20 |