| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,643 |
1,603 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
1,631 |
1,592 |
$45K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,644 |
1,604 |
$42K |
| D1351 |
Sealant - per tooth |
46 |
37 |
$5K |
| D0272 |
Bitewings - two radiographic images |
325 |
314 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
485 |
471 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
429 |
416 |
$2K |
| D0330 |
Panoramic radiographic image |
25 |
24 |
$519.80 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$219.70 |