| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
302 |
302 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
341 |
341 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
121 |
58 |
$8K |
| D1120 |
Prophylaxis - child |
135 |
135 |
$6K |
| D0330 |
Panoramic radiographic image |
129 |
129 |
$5K |
| D1206 |
Topical application of fluoride varnish |
148 |
148 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
51 |
51 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
72 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
56 |
56 |
$1K |
| D1351 |
Sealant - per tooth |
52 |
12 |
$1K |
| D0274 |
Bitewings - four radiographic images |
41 |
41 |
$480.00 |
| D0220 |
Intraoral - periapical first radiographic image |
135 |
135 |
$465.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
125 |
125 |
$411.00 |