| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,293 |
1,128 |
$53K |
| D0120 |
Periodic oral evaluation - established patient |
1,247 |
1,091 |
$35K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,282 |
1,119 |
$33K |
| D1351 |
Sealant - per tooth |
224 |
118 |
$17K |
| D0274 |
Bitewings - four radiographic images |
655 |
576 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
1,187 |
1,053 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,132 |
1,004 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
233 |
175 |
$3K |
| D1110 |
Prophylaxis - adult |
34 |
33 |
$1K |
| D0330 |
Panoramic radiographic image |
52 |
42 |
$1K |
| D0272 |
Bitewings - two radiographic images |
54 |
42 |
$488.80 |