| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,235 |
973 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,237 |
948 |
$27K |
| D1206 |
Topical application of fluoride varnish |
714 |
554 |
$15K |
| D0274 |
Bitewings - four radiographic images |
275 |
201 |
$4K |
| D1351 |
Sealant - per tooth |
16 |
12 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
296 |
210 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
153 |
98 |
$414.20 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$300.85 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$294.70 |