| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
395 |
365 |
$14K |
| D1351 |
Sealant - per tooth |
209 |
74 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
321 |
295 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
199 |
189 |
$4K |
| D1206 |
Topical application of fluoride varnish |
170 |
152 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
63 |
60 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
42 |
40 |
$853.80 |
| D0274 |
Bitewings - four radiographic images |
63 |
61 |
$743.60 |
| D0220 |
Intraoral - periapical first radiographic image |
124 |
115 |
$636.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
106 |
85 |
$551.00 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$122.20 |