| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,444 |
1,443 |
$28K |
| D1351 |
Sealant - per tooth |
1,120 |
391 |
$23K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
683 |
682 |
$18K |
| D1206 |
Topical application of fluoride varnish |
1,022 |
1,021 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
641 |
641 |
$11K |
| D0272 |
Bitewings - two radiographic images |
830 |
829 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
444 |
443 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
438 |
381 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
402 |
401 |
$2K |
| D1354 |
|
174 |
69 |
$2K |