| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
407 |
407 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
543 |
229 |
$21K |
| D1120 |
Prophylaxis - child |
290 |
289 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
52 |
52 |
$7K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
47 |
27 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
245 |
132 |
$5K |
| D0330 |
Panoramic radiographic image |
110 |
110 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
622 |
622 |
$385.92 |
| D1351 |
Sealant - per tooth |
191 |
43 |
$83.32 |
| D0274 |
Bitewings - four radiographic images |
421 |
421 |
$43.06 |
| D0272 |
Bitewings - two radiographic images |
220 |
220 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
14 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
598 |
597 |
$-169.81 |