| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
507 |
506 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
782 |
780 |
$14K |
| D9920 |
|
101 |
100 |
$12K |
| D0601 |
|
520 |
518 |
$5K |
| D1206 |
Topical application of fluoride varnish |
282 |
280 |
$5K |
| D1330 |
|
864 |
861 |
$4K |
| D1120 |
Prophylaxis - child |
122 |
120 |
$4K |
| D0274 |
Bitewings - four radiographic images |
122 |
122 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
37 |
26 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
31 |
19 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
78 |
78 |
$1K |
| D0602 |
|
146 |
145 |
$1K |
| D1351 |
Sealant - per tooth |
44 |
12 |
$1K |
| D0603 |
|
97 |
97 |
$950.00 |
| D0272 |
Bitewings - two radiographic images |
33 |
33 |
$504.00 |
| D0220 |
Intraoral - periapical first radiographic image |
31 |
31 |
$226.05 |