| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,150 |
1,597 |
$47K |
| D0330 |
Panoramic radiographic image |
792 |
713 |
$40K |
| D0120 |
Periodic oral evaluation - established patient |
1,395 |
1,222 |
$34K |
| D1206 |
Topical application of fluoride varnish |
1,652 |
1,181 |
$28K |
| D1351 |
Sealant - per tooth |
968 |
138 |
$24K |
| D0140 |
Limited oral evaluation - problem focused |
487 |
306 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
642 |
288 |
$10K |
| D0272 |
Bitewings - two radiographic images |
341 |
245 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
129 |
108 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$806.94 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
24 |
$277.20 |