| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,624 |
1,624 |
$62K |
| D0120 |
Periodic oral evaluation - established patient |
1,497 |
1,497 |
$41K |
| D1206 |
Topical application of fluoride varnish |
1,654 |
1,654 |
$37K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
750 |
523 |
$31K |
| D1351 |
Sealant - per tooth |
630 |
239 |
$21K |
| D0272 |
Bitewings - two radiographic images |
885 |
885 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
197 |
159 |
$11K |
| D1354 |
|
530 |
299 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
763 |
757 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
436 |
436 |
$6K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
28 |
25 |
$3K |
| D1330 |
|
242 |
242 |
$0.00 |
| D1310 |
|
241 |
241 |
$0.00 |
| D0191 |
|
37 |
37 |
$0.00 |