| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
642 |
642 |
$23K |
| D0274 |
Bitewings - four radiographic images |
507 |
506 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
630 |
626 |
$13K |
| D0330 |
Panoramic radiographic image |
256 |
255 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
200 |
199 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
153 |
151 |
$3K |
| D1351 |
Sealant - per tooth |
105 |
13 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
30 |
17 |
$2K |
| D1120 |
Prophylaxis - child |
48 |
48 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
123 |
121 |
$864.00 |