| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
736 |
736 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
382 |
382 |
$13K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
355 |
355 |
$12K |
| D1206 |
Topical application of fluoride varnish |
370 |
370 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
272 |
272 |
$4K |
| D0274 |
Bitewings - four radiographic images |
125 |
125 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
26 |
$3K |
| D1351 |
Sealant - per tooth |
29 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
15 |
12 |
$890.13 |
| D0220 |
Intraoral - periapical first radiographic image |
13 |
13 |
$210.38 |
| D0230 |
Intraoral - periapical each additional radiographic image |
12 |
12 |
$159.98 |