| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,030 |
1,027 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
918 |
914 |
$31K |
| D1208 |
Topical application of fluoride, excluding varnish |
991 |
988 |
$28K |
| D1351 |
Sealant - per tooth |
485 |
193 |
$19K |
| D0274 |
Bitewings - four radiographic images |
273 |
272 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
761 |
304 |
$12K |
| D0330 |
Panoramic radiographic image |
113 |
113 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
90 |
90 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
49 |
30 |
$4K |
| D0272 |
Bitewings - two radiographic images |
99 |
99 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
17 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$429.40 |