| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,863 |
1,640 |
$40K |
| D1351 |
Sealant - per tooth |
1,468 |
213 |
$34K |
| D0120 |
Periodic oral evaluation - established patient |
1,449 |
1,266 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,192 |
1,033 |
$14K |
| D0274 |
Bitewings - four radiographic images |
434 |
387 |
$10K |
| D0330 |
Panoramic radiographic image |
239 |
199 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
217 |
181 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
496 |
437 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
42 |
13 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
80 |
62 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
74 |
61 |
$958.20 |
| D0230 |
Intraoral - periapical each additional radiographic image |
85 |
54 |
$816.84 |