| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
314 |
313 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
276 |
276 |
$8K |
| D1206 |
Topical application of fluoride varnish |
299 |
298 |
$6K |
| D0272 |
Bitewings - two radiographic images |
156 |
156 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
16 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
235 |
105 |
$3K |
| D0274 |
Bitewings - four radiographic images |
60 |
60 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
58 |
58 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
124 |
122 |
$2K |
| D1351 |
Sealant - per tooth |
57 |
12 |
$2K |