| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
4,057 |
2,261 |
$38K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,602 |
1,764 |
$30K |
| D0140 |
Limited oral evaluation - problem focused |
1,099 |
646 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,758 |
1,387 |
$14K |
| D0272 |
Bitewings - two radiographic images |
1,803 |
1,070 |
$12K |
| D0330 |
Panoramic radiographic image |
610 |
334 |
$10K |
| D1206 |
Topical application of fluoride varnish |
879 |
638 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
265 |
258 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
379 |
216 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
287 |
163 |
$861.46 |