| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
592 |
586 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
376 |
376 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,107 |
679 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
142 |
141 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
595 |
589 |
$6K |
| D1351 |
Sealant - per tooth |
263 |
80 |
$5K |
| D0272 |
Bitewings - two radiographic images |
461 |
458 |
$5K |
| D2140 |
|
59 |
32 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
24 |
24 |
$920.00 |
| D0350 |
|
65 |
34 |
$487.20 |
| D9430 |
|
13 |
12 |
$364.00 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$130.00 |