| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
932 |
928 |
$57K |
| D1120 |
Prophylaxis - child |
89 |
89 |
$5K |
| D0274 |
Bitewings - four radiographic images |
746 |
745 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$440.40 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
27 |
$139.01 |
| D0120 |
Periodic oral evaluation - established patient |
1,046 |
1,042 |
$44.33 |
| D1206 |
Topical application of fluoride varnish |
509 |
508 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
68 |
68 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
95 |
95 |
$0.00 |
| D1351 |
Sealant - per tooth |
81 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
59 |
56 |
$-489.63 |