| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
280 |
280 |
$27K |
| D1120 |
Prophylaxis - child |
158 |
158 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
171 |
103 |
$12K |
| D0274 |
Bitewings - four radiographic images |
276 |
276 |
$764.23 |
| D1351 |
Sealant - per tooth |
522 |
85 |
$604.07 |
| D0330 |
Panoramic radiographic image |
46 |
46 |
$547.47 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
93 |
93 |
$404.19 |
| D0120 |
Periodic oral evaluation - established patient |
359 |
359 |
$52.03 |
| D0220 |
Intraoral - periapical first radiographic image |
365 |
355 |
$9.22 |
| D0230 |
Intraoral - periapical each additional radiographic image |
415 |
279 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
413 |
413 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
63 |
63 |
$0.00 |