| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
211 |
203 |
$8K |
| D1120 |
Prophylaxis - child |
247 |
238 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
124 |
123 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
51 |
51 |
$2K |
| D0274 |
Bitewings - four radiographic images |
75 |
70 |
$2K |
| D0330 |
Panoramic radiographic image |
28 |
27 |
$1K |
| D1206 |
Topical application of fluoride varnish |
38 |
34 |
$618.80 |
| D0220 |
Intraoral - periapical first radiographic image |
15 |
14 |
$172.38 |