| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
288 |
275 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
215 |
206 |
$5K |
| D1206 |
Topical application of fluoride varnish |
133 |
126 |
$3K |
| D1351 |
Sealant - per tooth |
19 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
68 |
67 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
223 |
206 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
192 |
178 |
$668.80 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
31 |
$652.55 |
| D0274 |
Bitewings - four radiographic images |
16 |
14 |
$219.70 |
| D0272 |
Bitewings - two radiographic images |
20 |
20 |
$188.00 |
| D0601 |
|
47 |
46 |
$0.00 |