| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,148 |
2,147 |
$92K |
| D1110 |
Prophylaxis - adult |
1,145 |
1,145 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,823 |
1,822 |
$26K |
| D0330 |
Panoramic radiographic image |
665 |
665 |
$26K |
| D0274 |
Bitewings - four radiographic images |
693 |
693 |
$20K |
| D0272 |
Bitewings - two radiographic images |
1,004 |
1,003 |
$18K |
| D1206 |
Topical application of fluoride varnish |
497 |
497 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
481 |
481 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
70 |
$2K |
| D1351 |
Sealant - per tooth |
43 |
13 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
70 |
70 |
$872.00 |