| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0140 |
Limited oral evaluation - problem focused |
388 |
313 |
$13K |
| D1120 |
Prophylaxis - child |
375 |
309 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
409 |
345 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
13 |
$3K |
| D1351 |
Sealant - per tooth |
88 |
13 |
$2K |
| D0274 |
Bitewings - four radiographic images |
61 |
58 |
$1K |
| D0330 |
Panoramic radiographic image |
30 |
26 |
$958.69 |
| D0120 |
Periodic oral evaluation - established patient |
13 |
12 |
$350.24 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
12 |
$133.40 |