| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
978 |
978 |
$34K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
247 |
96 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
493 |
493 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
405 |
405 |
$10K |
| D1206 |
Topical application of fluoride varnish |
298 |
298 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
611 |
611 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
627 |
626 |
$8K |
| D0272 |
Bitewings - two radiographic images |
322 |
322 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
110 |
110 |
$2K |
| D1351 |
Sealant - per tooth |
66 |
16 |
$2K |
| D1110 |
Prophylaxis - adult |
30 |
30 |
$1K |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$487.00 |
| D0274 |
Bitewings - four radiographic images |
14 |
14 |
$328.40 |