| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,203 |
1,135 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,083 |
1,028 |
$30K |
| D1206 |
Topical application of fluoride varnish |
676 |
645 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
367 |
346 |
$9K |
| D1351 |
Sealant - per tooth |
62 |
44 |
$7K |
| D0274 |
Bitewings - four radiographic images |
102 |
95 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
219 |
191 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
190 |
158 |
$911.12 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
18 |
$378.90 |
| D1354 |
|
14 |
13 |
$297.00 |
| D0272 |
Bitewings - two radiographic images |
25 |
25 |
$235.00 |