| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
474 |
474 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
313 |
313 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
198 |
198 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
355 |
355 |
$4K |
| D1206 |
Topical application of fluoride varnish |
151 |
151 |
$4K |
| D0272 |
Bitewings - two radiographic images |
187 |
187 |
$3K |
| D1351 |
Sealant - per tooth |
22 |
13 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$977.04 |
| D0330 |
Panoramic radiographic image |
25 |
25 |
$808.80 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$735.66 |
| D0240 |
|
12 |
12 |
$312.61 |