| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
184 |
182 |
$8K |
| D1206 |
Topical application of fluoride varnish |
224 |
222 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
155 |
153 |
$4K |
| D0274 |
Bitewings - four radiographic images |
130 |
127 |
$3K |
| D1120 |
Prophylaxis - child |
81 |
81 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
56 |
$2K |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
26 |
12 |
$2K |
| D1351 |
Sealant - per tooth |
59 |
16 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
47 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
204 |
133 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
115 |
106 |
$1K |
| D1330 |
|
17 |
17 |
$459.17 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$390.39 |