| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,914 |
1,507 |
$40K |
| D0330 |
Panoramic radiographic image |
871 |
669 |
$32K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,963 |
1,560 |
$24K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,102 |
740 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
716 |
660 |
$18K |
| D1351 |
Sealant - per tooth |
628 |
66 |
$17K |
| D0272 |
Bitewings - two radiographic images |
440 |
391 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
151 |
78 |
$3K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$400.18 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
12 |
$122.66 |