| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
317 |
312 |
$23K |
| D0120 |
Periodic oral evaluation - established patient |
449 |
446 |
$17K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
266 |
262 |
$15K |
| D1351 |
Sealant - per tooth |
354 |
69 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
70 |
33 |
$4K |
| D1120 |
Prophylaxis - child |
403 |
399 |
$3K |
| D1999 |
|
45 |
45 |
$2K |
| D0274 |
Bitewings - four radiographic images |
482 |
479 |
$1K |
| D1206 |
Topical application of fluoride varnish |
754 |
748 |
$941.38 |
| D1330 |
|
768 |
762 |
$449.46 |
| D0999 |
Unspecified diagnostic procedure, by report |
17 |
17 |
$340.00 |
| D9999 |
Unspecified adjunctive procedure, by report |
38 |
38 |
$340.00 |
| D0220 |
Intraoral - periapical first radiographic image |
575 |
567 |
$88.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$74.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
514 |
504 |
$47.84 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$24.46 |
| D0330 |
Panoramic radiographic image |
44 |
42 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
18 |
18 |
$0.00 |