| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
687 |
687 |
$56K |
| D0274 |
Bitewings - four radiographic images |
654 |
653 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
12 |
$2K |
| D1120 |
Prophylaxis - child |
32 |
32 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
14 |
14 |
$2K |
| D1351 |
Sealant - per tooth |
320 |
45 |
$687.39 |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$576.73 |
| D0220 |
Intraoral - periapical first radiographic image |
593 |
584 |
$17.41 |
| D0120 |
Periodic oral evaluation - established patient |
646 |
645 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
579 |
531 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
631 |
631 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
45 |
45 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
15 |
15 |
$0.00 |