| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
239 |
238 |
$9K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
127 |
68 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
120 |
52 |
$6K |
| D0330 |
Panoramic radiographic image |
146 |
145 |
$5K |
| D0274 |
Bitewings - four radiographic images |
165 |
164 |
$4K |
| D0120 |
Periodic oral evaluation - established patient |
152 |
151 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
129 |
129 |
$3K |
| D1351 |
Sealant - per tooth |
99 |
12 |
$3K |
| D1330 |
|
276 |
276 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
34 |
34 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
204 |
203 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
238 |
160 |
$978.45 |
| D1206 |
Topical application of fluoride varnish |
53 |
53 |
$919.45 |
| D9110 |
|
12 |
12 |
$382.50 |
| D1120 |
Prophylaxis - child |
14 |
14 |
$378.00 |