| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
722 |
675 |
$21K |
| D0274 |
Bitewings - four radiographic images |
375 |
342 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
95 |
55 |
$9K |
| D1206 |
Topical application of fluoride varnish |
373 |
349 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
175 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
277 |
252 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
160 |
131 |
$6K |
| D0330 |
Panoramic radiographic image |
60 |
57 |
$3K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
20 |
12 |
$3K |
| D1351 |
Sealant - per tooth |
52 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
44 |
43 |
$760.41 |