| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
191 |
191 |
$7K |
| D0120 |
Periodic oral evaluation - established patient |
167 |
167 |
$3K |
| D1351 |
Sealant - per tooth |
102 |
12 |
$3K |
| D0274 |
Bitewings - four radiographic images |
89 |
89 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
36 |
36 |
$2K |
| D1206 |
Topical application of fluoride varnish |
57 |
57 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
51 |
51 |
$1K |
| D9110 |
|
32 |
30 |
$964.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
17 |
14 |
$960.00 |
| D0220 |
Intraoral - periapical first radiographic image |
60 |
60 |
$472.00 |
| D1120 |
Prophylaxis - child |
13 |
13 |
$390.00 |