| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,666 |
1,651 |
$91K |
| D0330 |
Panoramic radiographic image |
1,489 |
1,478 |
$90K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,470 |
2,437 |
$73K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,260 |
2,236 |
$37K |
| D1351 |
Sealant - per tooth |
1,635 |
613 |
$35K |
| D1110 |
Prophylaxis - adult |
500 |
499 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
405 |
404 |
$10K |
| D0272 |
Bitewings - two radiographic images |
495 |
491 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
18 |
$934.18 |
| D0270 |
|
30 |
30 |
$307.30 |