| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
523 |
475 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
137 |
68 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
364 |
328 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
519 |
472 |
$8K |
| D0330 |
Panoramic radiographic image |
122 |
115 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
110 |
100 |
$5K |
| D0274 |
Bitewings - four radiographic images |
110 |
104 |
$3K |
| D1351 |
Sealant - per tooth |
70 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
20 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$304.14 |