| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,859 |
1,859 |
$80K |
| D0120 |
Periodic oral evaluation - established patient |
1,779 |
1,779 |
$52K |
| D1206 |
Topical application of fluoride varnish |
1,564 |
1,564 |
$47K |
| D1351 |
Sealant - per tooth |
414 |
131 |
$18K |
| D0272 |
Bitewings - two radiographic images |
1,014 |
1,014 |
$17K |
| D0220 |
Intraoral - periapical first radiographic image |
1,036 |
1,032 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
946 |
946 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
238 |
238 |
$3K |
| D1110 |
Prophylaxis - adult |
40 |
40 |
$2K |
| D0330 |
Panoramic radiographic image |
42 |
42 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
67 |
67 |
$1K |