| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,857 |
1,828 |
$84K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
3,240 |
3,168 |
$84K |
| D0330 |
Panoramic radiographic image |
2,019 |
1,985 |
$69K |
| D1351 |
Sealant - per tooth |
2,928 |
991 |
$46K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,610 |
2,553 |
$34K |
| D1110 |
Prophylaxis - adult |
588 |
577 |
$30K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
146 |
100 |
$6K |
| D0272 |
Bitewings - two radiographic images |
301 |
284 |
$4K |
| D0274 |
Bitewings - four radiographic images |
110 |
110 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
19 |
14 |
$1K |