| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
675 |
279 |
$32K |
| D1120 |
Prophylaxis - child |
514 |
495 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
572 |
545 |
$16K |
| D1206 |
Topical application of fluoride varnish |
462 |
443 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
16 |
16 |
$416.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
21 |
14 |
$378.90 |
| D0220 |
Intraoral - periapical first radiographic image |
36 |
35 |
$196.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
36 |
35 |
$148.20 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$122.20 |
| D0601 |
|
228 |
223 |
$0.00 |
| D0602 |
|
184 |
175 |
$0.00 |