| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
450 |
450 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
649 |
648 |
$17K |
| D1120 |
Prophylaxis - child |
277 |
276 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
162 |
162 |
$10K |
| D1351 |
Sealant - per tooth |
248 |
27 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
28 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
208 |
207 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
278 |
272 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
86 |
85 |
$4K |
| D1206 |
Topical application of fluoride varnish |
122 |
122 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
155 |
125 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
16 |
16 |
$711.78 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$655.69 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$209.37 |