| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
847 |
847 |
$48K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
482 |
336 |
$38K |
| D0120 |
Periodic oral evaluation - established patient |
768 |
768 |
$23K |
| D1120 |
Prophylaxis - child |
480 |
480 |
$20K |
| D0274 |
Bitewings - four radiographic images |
450 |
450 |
$16K |
| D0210 |
Intraoral - complete series of radiographic images |
165 |
165 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
295 |
295 |
$9K |
| D0330 |
Panoramic radiographic image |
115 |
115 |
$5K |
| D0272 |
Bitewings - two radiographic images |
216 |
216 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
38 |
31 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
41 |
27 |
$2K |
| D1206 |
Topical application of fluoride varnish |
69 |
69 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
140 |
140 |
$2K |
| D1351 |
Sealant - per tooth |
34 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
86 |
86 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
29 |
29 |
$521.50 |
| D9995 |
|
26 |
26 |
$0.00 |