| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,174 |
830 |
$22K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
590 |
372 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
350 |
296 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
671 |
563 |
$7K |
| D0274 |
Bitewings - four radiographic images |
210 |
182 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
133 |
116 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
446 |
333 |
$4K |
| D1206 |
Topical application of fluoride varnish |
147 |
91 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
102 |
66 |
$991.52 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$203.00 |
| D0330 |
Panoramic radiographic image |
24 |
13 |
$120.22 |