| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
554 |
473 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
701 |
599 |
$11K |
| D1110 |
Prophylaxis - adult |
294 |
246 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
683 |
581 |
$8K |
| D0330 |
Panoramic radiographic image |
189 |
165 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
93 |
37 |
$5K |
| D0272 |
Bitewings - two radiographic images |
172 |
143 |
$3K |
| D0274 |
Bitewings - four radiographic images |
104 |
86 |
$2K |
| D1351 |
Sealant - per tooth |
52 |
13 |
$787.00 |
| D0220 |
Intraoral - periapical first radiographic image |
98 |
79 |
$697.66 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
13 |
$354.90 |