| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0330 |
Panoramic radiographic image |
180 |
180 |
$7K |
| D0274 |
Bitewings - four radiographic images |
243 |
243 |
$6K |
| D1110 |
Prophylaxis - adult |
161 |
161 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
284 |
284 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
31 |
$5K |
| D1351 |
Sealant - per tooth |
125 |
13 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
21 |
20 |
$1K |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$680.00 |
| D1120 |
Prophylaxis - child |
12 |
12 |
$368.00 |
| D0220 |
Intraoral - periapical first radiographic image |
48 |
47 |
$292.00 |