| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
424 |
401 |
$14K |
| D0330 |
Panoramic radiographic image |
201 |
193 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
365 |
346 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
176 |
166 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
107 |
101 |
$4K |
| D1351 |
Sealant - per tooth |
96 |
16 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
49 |
41 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
20 |
14 |
$952.70 |
| D0272 |
Bitewings - two radiographic images |
14 |
12 |
$222.66 |