| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,176 |
1,056 |
$47K |
| D0120 |
Periodic oral evaluation - established patient |
1,075 |
973 |
$30K |
| D1206 |
Topical application of fluoride varnish |
578 |
495 |
$15K |
| D1208 |
Topical application of fluoride, excluding varnish |
527 |
498 |
$14K |
| D1351 |
Sealant - per tooth |
130 |
85 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
132 |
106 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
127 |
104 |
$5K |
| D0272 |
Bitewings - two radiographic images |
349 |
301 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
72 |
$2K |
| D0274 |
Bitewings - four radiographic images |
53 |
38 |
$861.90 |
| D0220 |
Intraoral - periapical first radiographic image |
131 |
114 |
$733.60 |
| D0230 |
Intraoral - periapical each additional radiographic image |
19 |
19 |
$72.20 |