| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
800 |
756 |
$31K |
| D1351 |
Sealant - per tooth |
503 |
202 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
867 |
820 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
713 |
678 |
$18K |
| D0274 |
Bitewings - four radiographic images |
193 |
187 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
532 |
490 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
481 |
417 |
$2K |
| D1206 |
Topical application of fluoride varnish |
64 |
58 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$547.30 |
| D0272 |
Bitewings - two radiographic images |
32 |
31 |
$300.80 |
| D1999 |
|
81 |
71 |
$0.00 |