| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
408 |
404 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
523 |
511 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
373 |
369 |
$9K |
| D1351 |
Sealant - per tooth |
27 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
62 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
233 |
224 |
$1K |
| D0274 |
Bitewings - four radiographic images |
59 |
59 |
$980.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
86 |
78 |
$813.20 |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
25 |
$676.80 |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$648.00 |