| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,670 |
1,639 |
$69K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,506 |
1,481 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,341 |
1,320 |
$38K |
| D0220 |
Intraoral - periapical first radiographic image |
685 |
668 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
516 |
513 |
$3K |
| D0272 |
Bitewings - two radiographic images |
66 |
66 |
$730.25 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$259.22 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$231.55 |