| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,021 |
1,012 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
628 |
624 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
907 |
901 |
$11K |
| D1351 |
Sealant - per tooth |
95 |
38 |
$6K |
| D0272 |
Bitewings - two radiographic images |
416 |
415 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
199 |
198 |
$5K |
| D0330 |
Panoramic radiographic image |
129 |
129 |
$3K |
| D0274 |
Bitewings - four radiographic images |
33 |
33 |
$850.68 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$450.00 |