| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,202 |
1,941 |
$54K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,562 |
1,321 |
$46K |
| D0140 |
Limited oral evaluation - problem focused |
1,126 |
1,028 |
$40K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,426 |
1,216 |
$19K |
| D0330 |
Panoramic radiographic image |
360 |
323 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
470 |
455 |
$12K |
| D1206 |
Topical application of fluoride varnish |
429 |
394 |
$9K |
| D1351 |
Sealant - per tooth |
81 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
52 |
29 |
$581.24 |