| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,030 |
977 |
$25K |
| D1351 |
Sealant - per tooth |
1,307 |
196 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
1,379 |
1,295 |
$22K |
| D0274 |
Bitewings - four radiographic images |
756 |
704 |
$17K |
| D1206 |
Topical application of fluoride varnish |
1,150 |
1,090 |
$16K |
| D1110 |
Prophylaxis - adult |
390 |
355 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
415 |
384 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
240 |
185 |
$2K |
| D0330 |
Panoramic radiographic image |
55 |
50 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
109 |
96 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
49 |
$1K |