| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
890 |
844 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
745 |
709 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
455 |
415 |
$11K |
| D1206 |
Topical application of fluoride varnish |
336 |
335 |
$9K |
| D0274 |
Bitewings - four radiographic images |
241 |
216 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
162 |
135 |
$3K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$369.00 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$361.20 |
| D0220 |
Intraoral - periapical first radiographic image |
73 |
66 |
$358.40 |
| D0230 |
Intraoral - periapical each additional radiographic image |
17 |
16 |
$106.40 |