| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
919 |
637 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
529 |
371 |
$13K |
| D0274 |
Bitewings - four radiographic images |
799 |
495 |
$13K |
| D1206 |
Topical application of fluoride varnish |
560 |
390 |
$8K |
| D1351 |
Sealant - per tooth |
641 |
58 |
$8K |
| D0330 |
Panoramic radiographic image |
110 |
106 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
317 |
182 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
27 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$939.58 |