| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
618 |
618 |
$27K |
| D0120 |
Periodic oral evaluation - established patient |
636 |
636 |
$17K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
104 |
55 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
586 |
583 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
691 |
536 |
$8K |
| D0272 |
Bitewings - two radiographic images |
293 |
292 |
$8K |
| D1206 |
Topical application of fluoride varnish |
376 |
376 |
$8K |
| D0274 |
Bitewings - four radiographic images |
96 |
96 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
25 |
$2K |
| D1351 |
Sealant - per tooth |
53 |
13 |
$1K |