| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
280 |
277 |
$8K |
| D1120 |
Prophylaxis - child |
145 |
144 |
$8K |
| D1110 |
Prophylaxis - adult |
144 |
142 |
$7K |
| D0274 |
Bitewings - four radiographic images |
133 |
132 |
$4K |
| D1351 |
Sealant - per tooth |
85 |
20 |
$2K |
| D1206 |
Topical application of fluoride varnish |
137 |
135 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
21 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
87 |
86 |
$1K |
| D0272 |
Bitewings - two radiographic images |
34 |
33 |
$536.76 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$363.00 |
| D0220 |
Intraoral - periapical first radiographic image |
24 |
22 |
$193.12 |
| D9986 |
|
20 |
20 |
$0.00 |