| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
324 |
291 |
$7K |
| D1351 |
Sealant - per tooth |
361 |
87 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
146 |
125 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
234 |
216 |
$5K |
| D1206 |
Topical application of fluoride varnish |
350 |
316 |
$5K |
| D0274 |
Bitewings - four radiographic images |
171 |
152 |
$3K |
| D0272 |
Bitewings - two radiographic images |
141 |
132 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
163 |
109 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
132 |
114 |
$1K |
| D1110 |
Prophylaxis - adult |
23 |
23 |
$667.00 |
| D0210 |
Intraoral - complete series of radiographic images |
27 |
16 |
$196.00 |