| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,611 |
1,312 |
$34K |
| D1351 |
Sealant - per tooth |
980 |
124 |
$22K |
| D1206 |
Topical application of fluoride varnish |
1,001 |
862 |
$17K |
| D0274 |
Bitewings - four radiographic images |
539 |
485 |
$13K |
| D0330 |
Panoramic radiographic image |
198 |
151 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
252 |
233 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
119 |
89 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
14 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
13 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
12 |
12 |
$342.00 |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$277.81 |