| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,060 |
666 |
$29K |
| D0120 |
Periodic oral evaluation - established patient |
968 |
598 |
$18K |
| D1206 |
Topical application of fluoride varnish |
972 |
598 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
231 |
118 |
$12K |
| D1351 |
Sealant - per tooth |
70 |
26 |
$4K |
| D0274 |
Bitewings - four radiographic images |
273 |
167 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
63 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
293 |
187 |
$1K |
| D0272 |
Bitewings - two radiographic images |
118 |
77 |
$770.80 |
| D0230 |
Intraoral - periapical each additional radiographic image |
203 |
123 |
$561.40 |