| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
571 |
551 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
744 |
716 |
$21K |
| D0330 |
Panoramic radiographic image |
241 |
232 |
$14K |
| D1351 |
Sealant - per tooth |
177 |
49 |
$6K |
| D1206 |
Topical application of fluoride varnish |
168 |
166 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
207 |
205 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
361 |
296 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
245 |
210 |
$3K |
| D1120 |
Prophylaxis - child |
69 |
69 |
$2K |
| D0272 |
Bitewings - two radiographic images |
87 |
87 |
$2K |