| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,764 |
1,614 |
$71K |
| D0120 |
Periodic oral evaluation - established patient |
1,393 |
1,298 |
$38K |
| D1206 |
Topical application of fluoride varnish |
1,455 |
1,334 |
$37K |
| D1351 |
Sealant - per tooth |
175 |
92 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,767 |
1,591 |
$10K |
| D0274 |
Bitewings - four radiographic images |
617 |
585 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,577 |
1,417 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
244 |
202 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
153 |
107 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
14 |
$1K |
| D0272 |
Bitewings - two radiographic images |
123 |
106 |
$1K |
| D0330 |
Panoramic radiographic image |
32 |
31 |
$384.20 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$178.20 |