| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,357 |
1,276 |
$54K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,362 |
1,278 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,034 |
989 |
$28K |
| D1351 |
Sealant - per tooth |
402 |
141 |
$24K |
| D0220 |
Intraoral - periapical first radiographic image |
1,372 |
1,279 |
$8K |
| D0274 |
Bitewings - four radiographic images |
392 |
353 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,317 |
1,231 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
220 |
179 |
$5K |
| D8670 |
Periodic orthodontic treatment visit |
12 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
90 |
78 |
$832.06 |