| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
354 |
319 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
371 |
339 |
$5K |
| D1206 |
Topical application of fluoride varnish |
66 |
58 |
$1K |
| D1120 |
Prophylaxis - child |
52 |
50 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
95 |
90 |
$714.98 |
| D0274 |
Bitewings - four radiographic images |
40 |
37 |
$482.49 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
12 |
$316.24 |
| D0230 |
Intraoral - periapical each additional radiographic image |
47 |
28 |
$95.19 |