| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,243 |
1,088 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,177 |
1,024 |
$25K |
| D0140 |
Limited oral evaluation - problem focused |
830 |
458 |
$25K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
591 |
473 |
$20K |
| D0330 |
Panoramic radiographic image |
422 |
335 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
477 |
448 |
$13K |
| D1351 |
Sealant - per tooth |
486 |
90 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
87 |
43 |
$12K |
| D0274 |
Bitewings - four radiographic images |
265 |
215 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
150 |
24 |
$4K |