| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
492 |
492 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
552 |
552 |
$18K |
| D1206 |
Topical application of fluoride varnish |
648 |
648 |
$17K |
| D1110 |
Prophylaxis - adult |
168 |
168 |
$11K |
| D1351 |
Sealant - per tooth |
107 |
16 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
74 |
74 |
$4K |
| D0272 |
Bitewings - two radiographic images |
206 |
206 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$3K |
| D0330 |
Panoramic radiographic image |
55 |
55 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
65 |
65 |
$2K |