| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
748 |
686 |
$36K |
| D1206 |
Topical application of fluoride varnish |
998 |
910 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
686 |
585 |
$23K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
65 |
26 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
46 |
27 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
169 |
151 |
$9K |
| D1110 |
Prophylaxis - adult |
131 |
121 |
$8K |
| D0350 |
|
107 |
101 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
203 |
177 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
247 |
140 |
$4K |
| D0330 |
Panoramic radiographic image |
39 |
38 |
$3K |
| D1351 |
Sealant - per tooth |
47 |
12 |
$2K |
| D0603 |
|
137 |
121 |
$0.00 |
| D0601 |
|
84 |
80 |
$0.00 |
| D0602 |
|
177 |
153 |
$0.00 |