| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
686 |
686 |
$25K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,102 |
1,102 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
858 |
858 |
$20K |
| D1110 |
Prophylaxis - adult |
133 |
133 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
15 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
146 |
146 |
$2K |
| D0330 |
Panoramic radiographic image |
36 |
36 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
29 |
29 |
$1K |
| D1351 |
Sealant - per tooth |
48 |
12 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
77 |
69 |
$605.35 |
| D0274 |
Bitewings - four radiographic images |
12 |
12 |
$245.00 |