| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
161 |
159 |
$8K |
| D1120 |
Prophylaxis - child |
201 |
199 |
$6K |
| D1206 |
Topical application of fluoride varnish |
204 |
201 |
$6K |
| D1351 |
Sealant - per tooth |
89 |
15 |
$3K |
| D9999 |
Unspecified adjunctive procedure, by report |
64 |
63 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
36 |
35 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
58 |
57 |
$505.12 |
| D0230 |
Intraoral - periapical each additional radiographic image |
75 |
54 |
$170.64 |
| D0272 |
Bitewings - two radiographic images |
14 |
13 |
$123.48 |