| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
137 |
137 |
$2K |
| D1206 |
Topical application of fluoride varnish |
155 |
155 |
$1K |
| D1110 |
Prophylaxis - adult |
63 |
63 |
$1K |
| D1120 |
Prophylaxis - child |
90 |
90 |
$1K |
| D0330 |
Panoramic radiographic image |
44 |
44 |
$1K |
| D0274 |
Bitewings - four radiographic images |
61 |
61 |
$829.00 |
| D0272 |
Bitewings - two radiographic images |
81 |
81 |
$756.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$440.00 |
| D1351 |
Sealant - per tooth |
32 |
14 |
$336.00 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
24 |
$141.00 |