| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
3,109 |
2,629 |
$67K |
| D1110 |
Prophylaxis - adult |
1,421 |
1,177 |
$42K |
| D1120 |
Prophylaxis - child |
1,710 |
1,450 |
$39K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,657 |
2,269 |
$38K |
| D0274 |
Bitewings - four radiographic images |
264 |
216 |
$6K |
| D1351 |
Sealant - per tooth |
124 |
31 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
323 |
128 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
187 |
169 |
$2K |
| D0272 |
Bitewings - two radiographic images |
131 |
122 |
$2K |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$743.40 |