| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
987 |
349 |
$50K |
| D1120 |
Prophylaxis - child |
1,256 |
1,207 |
$49K |
| D0120 |
Periodic oral evaluation - established patient |
1,046 |
1,012 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
595 |
565 |
$14K |
| D1206 |
Topical application of fluoride varnish |
340 |
329 |
$8K |
| D0274 |
Bitewings - four radiographic images |
445 |
424 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
174 |
164 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
440 |
418 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
461 |
443 |
$3K |
| D0272 |
Bitewings - two radiographic images |
64 |
57 |
$601.60 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$178.20 |
| D0601 |
|
228 |
221 |
$0.00 |
| D0602 |
|
28 |
28 |
$0.00 |