| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,103 |
913 |
$28K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
597 |
431 |
$18K |
| D0330 |
Panoramic radiographic image |
402 |
261 |
$11K |
| D1206 |
Topical application of fluoride varnish |
528 |
394 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
154 |
152 |
$4K |
| D0274 |
Bitewings - four radiographic images |
148 |
109 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
171 |
145 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
38 |
36 |
$1K |
| D0272 |
Bitewings - two radiographic images |
114 |
64 |
$980.78 |
| D0220 |
Intraoral - periapical first radiographic image |
115 |
64 |
$601.16 |