| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
563 |
563 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
657 |
657 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
239 |
239 |
$6K |
| D1206 |
Topical application of fluoride varnish |
228 |
228 |
$6K |
| D0274 |
Bitewings - four radiographic images |
184 |
184 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
374 |
373 |
$2K |
| D1351 |
Sealant - per tooth |
18 |
14 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
18 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
307 |
307 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
14 |
14 |
$339.04 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$133.08 |