| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,017 |
1,017 |
$46K |
| D1351 |
Sealant - per tooth |
822 |
138 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
855 |
855 |
$24K |
| D1206 |
Topical application of fluoride varnish |
915 |
915 |
$19K |
| D0272 |
Bitewings - two radiographic images |
665 |
665 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
241 |
241 |
$10K |
| D0330 |
Panoramic radiographic image |
129 |
129 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
423 |
422 |
$7K |
| D0274 |
Bitewings - four radiographic images |
118 |
118 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
318 |
310 |
$4K |