| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
290 |
264 |
$9K |
| D0274 |
Bitewings - four radiographic images |
134 |
117 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
142 |
130 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
93 |
76 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
47 |
$2K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$2K |
| D1206 |
Topical application of fluoride varnish |
54 |
45 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
54 |
$976.22 |