| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,547 |
1,547 |
$52K |
| D1206 |
Topical application of fluoride varnish |
934 |
934 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
915 |
915 |
$21K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
515 |
515 |
$12K |
| D0272 |
Bitewings - two radiographic images |
709 |
709 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
717 |
717 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
701 |
700 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
496 |
492 |
$3K |
| D1351 |
Sealant - per tooth |
94 |
24 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$288.25 |