| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,058 |
1,058 |
$40K |
| D1351 |
Sealant - per tooth |
862 |
329 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
995 |
995 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
847 |
847 |
$22K |
| D0240 |
|
576 |
288 |
$12K |
| D0274 |
Bitewings - four radiographic images |
260 |
260 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
178 |
178 |
$8K |
| D1206 |
Topical application of fluoride varnish |
77 |
77 |
$692.17 |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$654.59 |
| D0220 |
Intraoral - periapical first radiographic image |
30 |
30 |
$209.66 |
| D0230 |
Intraoral - periapical each additional radiographic image |
30 |
30 |
$111.02 |