| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
383 |
383 |
$14K |
| D1206 |
Topical application of fluoride varnish |
586 |
586 |
$14K |
| D1351 |
Sealant - per tooth |
257 |
41 |
$7K |
| D1110 |
Prophylaxis - adult |
98 |
98 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
166 |
166 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
54 |
54 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$2K |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$424.57 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$300.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$187.00 |