| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
9,789 |
1,516 |
$149K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,892 |
2,112 |
$78K |
| D1120 |
Prophylaxis - child |
3,365 |
2,394 |
$45K |
| D1206 |
Topical application of fluoride varnish |
2,540 |
2,134 |
$41K |
| D0272 |
Bitewings - two radiographic images |
3,137 |
2,267 |
$32K |
| D0140 |
Limited oral evaluation - problem focused |
247 |
187 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
464 |
134 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$362.53 |
| D0120 |
Periodic oral evaluation - established patient |
30 |
30 |
$0.00 |