| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,516 |
1,458 |
$62K |
| D1206 |
Topical application of fluoride varnish |
1,569 |
1,506 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
838 |
794 |
$23K |
| D1351 |
Sealant - per tooth |
115 |
73 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
249 |
243 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
26 |
$3K |
| D0330 |
Panoramic radiographic image |
54 |
49 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
130 |
126 |
$853.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
79 |
79 |
$358.40 |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$245.88 |