| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
916 |
810 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
520 |
456 |
$13K |
| D1206 |
Topical application of fluoride varnish |
473 |
412 |
$10K |
| D0274 |
Bitewings - four radiographic images |
293 |
255 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
117 |
$5K |
| D0330 |
Panoramic radiographic image |
104 |
90 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
139 |
124 |
$2K |
| D1351 |
Sealant - per tooth |
72 |
13 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
67 |
58 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
15 |
$213.47 |