| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
463 |
456 |
$21K |
| D0330 |
Panoramic radiographic image |
556 |
539 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
705 |
685 |
$15K |
| D1351 |
Sealant - per tooth |
834 |
290 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
713 |
695 |
$10K |
| D0274 |
Bitewings - four radiographic images |
410 |
397 |
$9K |
| D1110 |
Prophylaxis - adult |
170 |
162 |
$7K |
| D0272 |
Bitewings - two radiographic images |
294 |
279 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
45 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
27 |
22 |
$2K |
| D9110 |
|
13 |
13 |
$319.41 |