| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
588 |
580 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
502 |
493 |
$13K |
| D1351 |
Sealant - per tooth |
173 |
106 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
288 |
286 |
$7K |
| D0274 |
Bitewings - four radiographic images |
123 |
123 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
346 |
338 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
76 |
76 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
289 |
283 |
$1K |
| D0272 |
Bitewings - two radiographic images |
106 |
104 |
$968.20 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$0.00 |