| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
537 |
521 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
322 |
304 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
360 |
354 |
$9K |
| D1206 |
Topical application of fluoride varnish |
291 |
284 |
$6K |
| D0330 |
Panoramic radiographic image |
86 |
86 |
$5K |
| D0274 |
Bitewings - four radiographic images |
119 |
116 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
141 |
139 |
$2K |
| D1351 |
Sealant - per tooth |
83 |
28 |
$2K |
| D0272 |
Bitewings - two radiographic images |
77 |
73 |
$1K |