| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,391 |
1,331 |
$75K |
| D1351 |
Sealant - per tooth |
1,268 |
459 |
$51K |
| D1206 |
Topical application of fluoride varnish |
1,617 |
1,551 |
$51K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
728 |
691 |
$48K |
| D0330 |
Panoramic radiographic image |
415 |
415 |
$43K |
| D0272 |
Bitewings - two radiographic images |
1,140 |
1,095 |
$42K |
| D0120 |
Periodic oral evaluation - established patient |
865 |
845 |
$33K |
| D0274 |
Bitewings - four radiographic images |
90 |
87 |
$4K |
| D1110 |
Prophylaxis - adult |
56 |
52 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
75 |
73 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$1K |