| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
212 |
210 |
$7K |
| D0274 |
Bitewings - four radiographic images |
179 |
177 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
178 |
176 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
173 |
173 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
180 |
179 |
$3K |
| D1351 |
Sealant - per tooth |
130 |
29 |
$3K |
| D1120 |
Prophylaxis - child |
103 |
102 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
138 |
138 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$883.66 |
| D0230 |
Intraoral - periapical each additional radiographic image |
113 |
98 |
$783.20 |
| D0272 |
Bitewings - two radiographic images |
14 |
13 |
$196.56 |