| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,421 |
1,347 |
$56K |
| D0120 |
Periodic oral evaluation - established patient |
1,148 |
1,090 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
427 |
410 |
$11K |
| D1351 |
Sealant - per tooth |
24 |
12 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
335 |
309 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
284 |
264 |
$949.64 |
| D0272 |
Bitewings - two radiographic images |
100 |
85 |
$930.60 |
| D0274 |
Bitewings - four radiographic images |
52 |
52 |
$886.22 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
15 |
$378.90 |