| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
280 |
280 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
202 |
202 |
$5K |
| D1120 |
Prophylaxis - child |
95 |
95 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
256 |
256 |
$3K |
| D1351 |
Sealant - per tooth |
72 |
13 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
227 |
227 |
$1K |
| D0272 |
Bitewings - two radiographic images |
61 |
61 |
$842.52 |
| D0274 |
Bitewings - four radiographic images |
53 |
53 |
$803.88 |
| D1208 |
Topical application of fluoride, excluding varnish |
38 |
38 |
$446.88 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$374.40 |