| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
591 |
591 |
$25K |
| D0120 |
Periodic oral evaluation - established patient |
758 |
758 |
$21K |
| D0274 |
Bitewings - four radiographic images |
649 |
649 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
756 |
756 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
704 |
704 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
68 |
$6K |
| D1351 |
Sealant - per tooth |
48 |
15 |
$2K |
| D7140 |
Extraction, erupted tooth or exposed root |
19 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
22 |
13 |
$1K |