| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
780 |
780 |
$29K |
| D1351 |
Sealant - per tooth |
614 |
192 |
$18K |
| D1206 |
Topical application of fluoride varnish |
806 |
806 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
367 |
367 |
$16K |
| D0120 |
Periodic oral evaluation - established patient |
395 |
395 |
$10K |
| D0274 |
Bitewings - four radiographic images |
272 |
272 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
307 |
307 |
$5K |
| D0272 |
Bitewings - two radiographic images |
147 |
147 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
317 |
293 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
16 |
16 |
$464.00 |