| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
1,666 |
1,666 |
$96K |
| D1120 |
Prophylaxis - child |
1,572 |
1,572 |
$67K |
| D0120 |
Periodic oral evaluation - established patient |
1,406 |
1,406 |
$43K |
| D1351 |
Sealant - per tooth |
1,012 |
303 |
$38K |
| D0274 |
Bitewings - four radiographic images |
647 |
647 |
$24K |
| D0330 |
Panoramic radiographic image |
478 |
478 |
$23K |
| D1206 |
Topical application of fluoride varnish |
751 |
751 |
$21K |
| D0272 |
Bitewings - two radiographic images |
724 |
724 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
269 |
269 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
197 |
196 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
33 |
29 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
132 |
131 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$773.00 |
| D1320 |
|
13 |
13 |
$114.00 |
| D9995 |
|
14 |
14 |
$0.00 |
| D1330 |
|
74 |
74 |
$0.00 |