| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D9920 |
|
12 |
12 |
$612.28 |
| D1120 |
Prophylaxis - child |
281 |
266 |
$603.54 |
| D1206 |
Topical application of fluoride varnish |
268 |
249 |
$599.11 |
| D0120 |
Periodic oral evaluation - established patient |
324 |
307 |
$597.68 |
| D0274 |
Bitewings - four radiographic images |
154 |
154 |
$507.66 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
13 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
59 |
59 |
$0.00 |
| D1351 |
Sealant - per tooth |
56 |
18 |
$0.00 |
| D1110 |
Prophylaxis - adult |
114 |
106 |
$0.00 |
| D0330 |
Panoramic radiographic image |
111 |
101 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
53 |
52 |
$0.00 |