| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
803 |
764 |
$37K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,115 |
1,046 |
$30K |
| D0120 |
Periodic oral evaluation - established patient |
999 |
936 |
$26K |
| D8670 |
Periodic orthodontic treatment visit |
88 |
70 |
$17K |
| D1110 |
Prophylaxis - adult |
199 |
188 |
$12K |
| D0274 |
Bitewings - four radiographic images |
189 |
175 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
38 |
$2K |
| D1351 |
Sealant - per tooth |
46 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$420.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$364.00 |