| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
465 |
465 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
713 |
712 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
613 |
609 |
$16K |
| D1110 |
Prophylaxis - adult |
309 |
309 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
113 |
113 |
$8K |
| D1351 |
Sealant - per tooth |
200 |
57 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
129 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
339 |
338 |
$6K |
| D0274 |
Bitewings - four radiographic images |
137 |
137 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
262 |
256 |
$2K |
| D0272 |
Bitewings - two radiographic images |
28 |
28 |
$687.60 |