| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
496 |
496 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
667 |
667 |
$19K |
| D1120 |
Prophylaxis - child |
468 |
468 |
$19K |
| D0140 |
Limited oral evaluation - problem focused |
593 |
587 |
$11K |
| D0274 |
Bitewings - four radiographic images |
253 |
253 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
483 |
482 |
$7K |
| D1206 |
Topical application of fluoride varnish |
226 |
225 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
181 |
181 |
$5K |
| D1351 |
Sealant - per tooth |
87 |
25 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
28 |
28 |
$2K |
| D0330 |
Panoramic radiographic image |
27 |
27 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
13 |
12 |
$715.00 |
| D1999 |
|
28 |
28 |
$0.00 |