| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
850 |
790 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
797 |
756 |
$20K |
| D1351 |
Sealant - per tooth |
734 |
127 |
$17K |
| D0272 |
Bitewings - two radiographic images |
633 |
601 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
1,173 |
1,094 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,069 |
1,001 |
$9K |
| D1206 |
Topical application of fluoride varnish |
710 |
658 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
138 |
118 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
27 |
27 |
$4K |
| D0330 |
Panoramic radiographic image |
102 |
83 |
$3K |
| D1110 |
Prophylaxis - adult |
51 |
50 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
167 |
161 |
$2K |
| D0274 |
Bitewings - four radiographic images |
54 |
54 |
$1K |
| D0601 |
|
1,218 |
1,156 |
$0.00 |
| D0602 |
|
67 |
64 |
$0.00 |
| D0603 |
|
30 |
30 |
$0.00 |