| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,554 |
1,489 |
$64K |
| D0120 |
Periodic oral evaluation - established patient |
1,008 |
959 |
$28K |
| D1206 |
Topical application of fluoride varnish |
749 |
721 |
$20K |
| D1351 |
Sealant - per tooth |
98 |
78 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
270 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
906 |
874 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
12 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
650 |
629 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$1K |
| D0272 |
Bitewings - two radiographic images |
116 |
115 |
$1K |
| D0274 |
Bitewings - four radiographic images |
54 |
54 |
$897.30 |
| D0330 |
Panoramic radiographic image |
18 |
15 |
$384.20 |