| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
293 |
293 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
263 |
263 |
$7K |
| D1206 |
Topical application of fluoride varnish |
278 |
278 |
$6K |
| D0272 |
Bitewings - two radiographic images |
190 |
190 |
$5K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$4K |
| D0274 |
Bitewings - four radiographic images |
88 |
88 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
224 |
224 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
60 |
60 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
168 |
163 |
$2K |
| D1351 |
Sealant - per tooth |
58 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$1K |