| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
401 |
401 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
413 |
413 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
535 |
532 |
$8K |
| D1206 |
Topical application of fluoride varnish |
360 |
360 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
463 |
453 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
80 |
39 |
$5K |
| D0272 |
Bitewings - two radiographic images |
136 |
136 |
$4K |
| D0330 |
Panoramic radiographic image |
50 |
50 |
$4K |
| D0274 |
Bitewings - four radiographic images |
55 |
55 |
$2K |