| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
949 |
949 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
917 |
917 |
$25K |
| D1120 |
Prophylaxis - child |
376 |
376 |
$15K |
| D0274 |
Bitewings - four radiographic images |
344 |
344 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
482 |
482 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
321 |
319 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
37 |
37 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
127 |
127 |
$3K |
| D0272 |
Bitewings - two radiographic images |
122 |
122 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
76 |
72 |
$2K |
| D1351 |
Sealant - per tooth |
23 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
41 |
41 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
96 |
96 |
$1K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$330.00 |
| D0180 |
|
14 |
14 |
$0.00 |