| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
763 |
763 |
$15K |
| D1206 |
Topical application of fluoride varnish |
533 |
533 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
247 |
247 |
$6K |
| D1351 |
Sealant - per tooth |
298 |
124 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
349 |
349 |
$6K |
| D1354 |
|
382 |
112 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
251 |
251 |
$4K |
| D0272 |
Bitewings - two radiographic images |
315 |
315 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
110 |
110 |
$550.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
76 |
$395.00 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$240.00 |