| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
120 |
118 |
$11K |
| D0330 |
Panoramic radiographic image |
92 |
92 |
$11K |
| D1206 |
Topical application of fluoride varnish |
251 |
247 |
$9K |
| D1110 |
Prophylaxis - adult |
64 |
62 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
222 |
210 |
$3K |
| D1351 |
Sealant - per tooth |
106 |
23 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
15 |
$3K |
| D0274 |
Bitewings - four radiographic images |
87 |
87 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
40 |
40 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
264 |
147 |
$1K |
| D0120 |
Periodic oral evaluation - established patient |
57 |
57 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
37 |
35 |
$561.00 |