| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
265 |
256 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
357 |
346 |
$7K |
| D1206 |
Topical application of fluoride varnish |
221 |
218 |
$4K |
| D0274 |
Bitewings - four radiographic images |
133 |
133 |
$3K |
| D1120 |
Prophylaxis - child |
106 |
106 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
25 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
41 |
41 |
$946.11 |
| D1351 |
Sealant - per tooth |
38 |
12 |
$844.74 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$589.89 |
| D1330 |
|
16 |
14 |
$314.40 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$298.30 |