| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,017 |
1,016 |
$21K |
| D1351 |
Sealant - per tooth |
896 |
292 |
$21K |
| D1206 |
Topical application of fluoride varnish |
883 |
883 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
436 |
436 |
$12K |
| D1354 |
|
783 |
270 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
426 |
426 |
$8K |
| D0272 |
Bitewings - two radiographic images |
425 |
425 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
168 |
168 |
$2K |
| D0274 |
Bitewings - four radiographic images |
32 |
32 |
$640.00 |
| D0220 |
Intraoral - periapical first radiographic image |
109 |
109 |
$617.45 |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
79 |
$452.96 |