| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
368 |
368 |
$7K |
| D1351 |
Sealant - per tooth |
231 |
83 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
156 |
156 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
239 |
239 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
150 |
150 |
$2K |
| D0272 |
Bitewings - two radiographic images |
215 |
215 |
$2K |
| D1206 |
Topical application of fluoride varnish |
132 |
132 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
111 |
110 |
$600.00 |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
111 |
$555.00 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$260.00 |