| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
909 |
909 |
$52K |
| D0274 |
Bitewings - four radiographic images |
746 |
746 |
$26K |
| D0120 |
Periodic oral evaluation - established patient |
829 |
828 |
$25K |
| D1120 |
Prophylaxis - child |
532 |
532 |
$23K |
| D1351 |
Sealant - per tooth |
307 |
101 |
$12K |
| D0330 |
Panoramic radiographic image |
168 |
168 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
215 |
215 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
381 |
375 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
57 |
54 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
217 |
214 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
50 |
41 |
$3K |
| D0272 |
Bitewings - two radiographic images |
137 |
137 |
$3K |
| D9110 |
|
28 |
28 |
$827.18 |
| D1206 |
Topical application of fluoride varnish |
24 |
24 |
$655.50 |
| D9995 |
|
29 |
29 |
$0.00 |