| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
584 |
584 |
$3K |
| D1351 |
Sealant - per tooth |
528 |
194 |
$3K |
| D1330 |
|
648 |
648 |
$3K |
| D1206 |
Topical application of fluoride varnish |
645 |
644 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
310 |
310 |
$823.59 |
| D0272 |
Bitewings - two radiographic images |
302 |
302 |
$778.41 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
94 |
68 |
$446.67 |
| D0274 |
Bitewings - four radiographic images |
55 |
55 |
$104.73 |
| D9920 |
|
32 |
32 |
$40.17 |
| D2150 |
Silver amalgam - two surfaces, primary or permanent |
43 |
29 |
$0.00 |
| D2140 |
|
35 |
27 |
$0.00 |
| D1110 |
Prophylaxis - adult |
20 |
20 |
$0.00 |
| D7111 |
|
46 |
24 |
$0.00 |
| D9215 |
|
24 |
16 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
106 |
75 |
$0.00 |