| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
440 |
341 |
$15K |
| D1120 |
Prophylaxis - child |
651 |
485 |
$15K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
404 |
254 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
95 |
86 |
$3K |
| D0330 |
Panoramic radiographic image |
59 |
53 |
$3K |
| D0274 |
Bitewings - four radiographic images |
60 |
59 |
$2K |
| D1206 |
Topical application of fluoride varnish |
59 |
50 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
65 |
17 |
$292.18 |
| D0220 |
Intraoral - periapical first radiographic image |
17 |
14 |
$133.40 |