| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
557 |
523 |
$17K |
| D1206 |
Topical application of fluoride varnish |
368 |
359 |
$9K |
| D1351 |
Sealant - per tooth |
238 |
40 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
216 |
211 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
106 |
$4K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
31 |
27 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
39 |
38 |
$833.04 |
| D0220 |
Intraoral - periapical first radiographic image |
21 |
19 |
$289.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
15 |
13 |
$173.84 |