| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
603 |
603 |
$26K |
| D1351 |
Sealant - per tooth |
818 |
184 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
580 |
580 |
$15K |
| D1206 |
Topical application of fluoride varnish |
624 |
624 |
$12K |
| D0272 |
Bitewings - two radiographic images |
287 |
287 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
492 |
490 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
475 |
442 |
$6K |
| D0274 |
Bitewings - four radiographic images |
100 |
100 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
17 |
13 |
$1K |