| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
8,271 |
8,264 |
$315K |
| D1206 |
Topical application of fluoride varnish |
8,466 |
8,457 |
$196K |
| D1351 |
Sealant - per tooth |
5,476 |
1,948 |
$156K |
| D0120 |
Periodic oral evaluation - established patient |
5,198 |
5,190 |
$134K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,908 |
2,908 |
$126K |
| D1110 |
Prophylaxis - adult |
293 |
290 |
$15K |
| D0145 |
Oral evaluation for a patient under three years of age |
292 |
292 |
$8K |
| D0191 |
|
141 |
141 |
$2K |
| D0272 |
Bitewings - two radiographic images |
50 |
50 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
70 |
14 |
$585.00 |
| D0274 |
Bitewings - four radiographic images |
19 |
19 |
$518.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
17 |
$336.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$221.00 |