| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
440 |
392 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
462 |
407 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
396 |
349 |
$10K |
| D1351 |
Sealant - per tooth |
90 |
55 |
$6K |
| D0274 |
Bitewings - four radiographic images |
255 |
222 |
$4K |
| D0330 |
Panoramic radiographic image |
63 |
55 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
50 |
42 |
$1K |
| D0272 |
Bitewings - two radiographic images |
79 |
69 |
$714.40 |
| D1110 |
Prophylaxis - adult |
16 |
16 |
$428.00 |
| D1206 |
Topical application of fluoride varnish |
16 |
15 |
$390.00 |
| D0220 |
Intraoral - periapical first radiographic image |
66 |
58 |
$369.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
32 |
26 |
$239.40 |