| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
861 |
861 |
$39K |
| D1206 |
Topical application of fluoride varnish |
939 |
939 |
$29K |
| D1351 |
Sealant - per tooth |
1,061 |
210 |
$21K |
| D0120 |
Periodic oral evaluation - established patient |
731 |
731 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
257 |
151 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
224 |
134 |
$12K |
| D9920 |
|
279 |
274 |
$7K |
| D0330 |
Panoramic radiographic image |
168 |
168 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
194 |
194 |
$5K |
| D0272 |
Bitewings - two radiographic images |
419 |
419 |
$4K |
| D0603 |
|
299 |
299 |
$3K |
| D0274 |
Bitewings - four radiographic images |
239 |
239 |
$3K |
| D0602 |
|
142 |
142 |
$1K |
| D0601 |
|
127 |
127 |
$1K |
| D1110 |
Prophylaxis - adult |
26 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$540.00 |
| D0220 |
Intraoral - periapical first radiographic image |
80 |
80 |
$400.00 |