| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
770 |
743 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
764 |
739 |
$19K |
| D1351 |
Sealant - per tooth |
113 |
70 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
280 |
267 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
52 |
$6K |
| D0274 |
Bitewings - four radiographic images |
276 |
273 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
68 |
67 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
13 |
$462.75 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$133.08 |