| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,172 |
1,747 |
$46K |
| D0330 |
Panoramic radiographic image |
983 |
778 |
$33K |
| D0274 |
Bitewings - four radiographic images |
1,741 |
1,370 |
$31K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,280 |
951 |
$30K |
| D1206 |
Topical application of fluoride varnish |
1,256 |
958 |
$19K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
204 |
78 |
$19K |
| D0120 |
Periodic oral evaluation - established patient |
615 |
539 |
$15K |
| D0140 |
Limited oral evaluation - problem focused |
448 |
366 |
$15K |
| D1351 |
Sealant - per tooth |
188 |
26 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
219 |
197 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
261 |
217 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
16 |
12 |
$2K |