| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
590 |
549 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
340 |
322 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
313 |
301 |
$7K |
| D1206 |
Topical application of fluoride varnish |
245 |
219 |
$5K |
| D1351 |
Sealant - per tooth |
118 |
74 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
29 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
109 |
92 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
123 |
112 |
$536.43 |
| D0274 |
Bitewings - four radiographic images |
24 |
24 |
$405.60 |
| D0272 |
Bitewings - two radiographic images |
43 |
42 |
$366.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
93 |
83 |
$293.55 |
| D0601 |
|
71 |
62 |
$0.00 |
| D0602 |
|
31 |
31 |
$0.00 |
| D1330 |
|
52 |
45 |
$0.00 |