| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
198 |
197 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
142 |
141 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
118 |
118 |
$3K |
| D1206 |
Topical application of fluoride varnish |
77 |
76 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
32 |
32 |
$2K |
| D1351 |
Sealant - per tooth |
47 |
18 |
$2K |
| D0330 |
Panoramic radiographic image |
20 |
20 |
$2K |
| D0272 |
Bitewings - two radiographic images |
43 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
29 |
28 |
$539.98 |
| D0230 |
Intraoral - periapical each additional radiographic image |
25 |
24 |
$416.50 |