| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,117 |
848 |
$24K |
| D1206 |
Topical application of fluoride varnish |
968 |
730 |
$17K |
| D0274 |
Bitewings - four radiographic images |
872 |
646 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
574 |
463 |
$15K |
| D0330 |
Panoramic radiographic image |
271 |
197 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
336 |
284 |
$7K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
24 |
15 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
30 |
26 |
$916.56 |
| D0220 |
Intraoral - periapical first radiographic image |
128 |
58 |
$565.34 |
| D1208 |
Topical application of fluoride, excluding varnish |
12 |
12 |
$226.96 |