| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
397 |
391 |
$12K |
| D1120 |
Prophylaxis - child |
592 |
584 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
235 |
228 |
$2K |
| D0330 |
Panoramic radiographic image |
82 |
82 |
$2K |
| D1206 |
Topical application of fluoride varnish |
167 |
166 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
193 |
145 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
169 |
163 |
$1K |
| D1351 |
Sealant - per tooth |
54 |
14 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
38 |
38 |
$803.00 |
| D0272 |
Bitewings - two radiographic images |
17 |
17 |
$255.00 |