| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
183 |
182 |
$11K |
| D1206 |
Topical application of fluoride varnish |
274 |
273 |
$9K |
| D0330 |
Panoramic radiographic image |
70 |
69 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
161 |
161 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
82 |
81 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
32 |
$4K |
| D1351 |
Sealant - per tooth |
85 |
27 |
$4K |
| D0272 |
Bitewings - two radiographic images |
74 |
74 |
$3K |
| D1110 |
Prophylaxis - adult |
31 |
31 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
16 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
100 |
98 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$2K |
| D0274 |
Bitewings - four radiographic images |
33 |
32 |
$2K |