| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
285 |
285 |
$12K |
| D1351 |
Sealant - per tooth |
83 |
65 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
282 |
282 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
245 |
245 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
26 |
23 |
$3K |
| D0274 |
Bitewings - four radiographic images |
114 |
114 |
$2K |
| D0330 |
Panoramic radiographic image |
61 |
61 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
221 |
219 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
212 |
212 |
$964.11 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$678.08 |
| D0272 |
Bitewings - two radiographic images |
33 |
33 |
$365.97 |