| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
149 |
149 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
162 |
160 |
$4K |
| D1110 |
Prophylaxis - adult |
99 |
99 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
166 |
164 |
$3K |
| D1351 |
Sealant - per tooth |
29 |
24 |
$3K |
| D0274 |
Bitewings - four radiographic images |
148 |
147 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
32 |
26 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
83 |
81 |
$2K |
| D1206 |
Topical application of fluoride varnish |
77 |
77 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
208 |
200 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
177 |
172 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
30 |
30 |
$780.00 |
| D0272 |
Bitewings - two radiographic images |
32 |
32 |
$300.80 |
| D1999 |
|
86 |
85 |
$0.00 |