| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9920 |
|
406 |
373 |
$45K |
| D1110 |
Prophylaxis - adult |
327 |
327 |
$12K |
| D1351 |
Sealant - per tooth |
457 |
62 |
$12K |
| D0274 |
Bitewings - four radiographic images |
418 |
418 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
158 |
104 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
242 |
242 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
201 |
201 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
105 |
64 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
121 |
121 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
366 |
341 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
118 |
118 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
212 |
195 |
$2K |
| D1330 |
|
187 |
187 |
$1K |
| D1120 |
Prophylaxis - child |
36 |
36 |
$1K |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$258.88 |
| D0601 |
|
17 |
17 |
$150.00 |