| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
470 |
431 |
$25K |
| D1206 |
Topical application of fluoride varnish |
456 |
417 |
$22K |
| D1351 |
Sealant - per tooth |
671 |
200 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
350 |
339 |
$11K |
| D0272 |
Bitewings - two radiographic images |
275 |
254 |
$5K |
| D0330 |
Panoramic radiographic image |
97 |
88 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
206 |
182 |
$3K |
| D0274 |
Bitewings - four radiographic images |
108 |
94 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
23 |
16 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
372 |
213 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
64 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
123 |
95 |
$2K |
| D0240 |
|
114 |
65 |
$1K |
| D0350 |
|
17 |
16 |
$225.50 |