| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,461 |
1,461 |
$40K |
| D1120 |
Prophylaxis - child |
948 |
948 |
$39K |
| D1110 |
Prophylaxis - adult |
418 |
418 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,102 |
1,102 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
137 |
96 |
$12K |
| D0274 |
Bitewings - four radiographic images |
422 |
422 |
$12K |
| D1206 |
Topical application of fluoride varnish |
184 |
184 |
$5K |
| D1351 |
Sealant - per tooth |
82 |
39 |
$5K |
| D0330 |
Panoramic radiographic image |
54 |
54 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
43 |
43 |
$1K |
| D0272 |
Bitewings - two radiographic images |
27 |
27 |
$434.35 |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$344.04 |