| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,491 |
2,126 |
$60K |
| D0120 |
Periodic oral evaluation - established patient |
1,463 |
1,313 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,578 |
1,336 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,026 |
808 |
$30K |
| D0330 |
Panoramic radiographic image |
408 |
363 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
536 |
481 |
$8K |
| D0272 |
Bitewings - two radiographic images |
509 |
395 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
43 |
38 |
$1K |
| D1351 |
Sealant - per tooth |
62 |
12 |
$975.19 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
12 |
$913.16 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$305.10 |