| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
987 |
976 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
725 |
721 |
$23K |
| D0272 |
Bitewings - two radiographic images |
646 |
640 |
$18K |
| D1206 |
Topical application of fluoride varnish |
978 |
968 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
539 |
531 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
490 |
481 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
170 |
165 |
$8K |
| D1351 |
Sealant - per tooth |
189 |
29 |
$6K |
| D0330 |
Panoramic radiographic image |
39 |
39 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
40 |
40 |
$2K |