| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
259 |
252 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
340 |
334 |
$12K |
| D1351 |
Sealant - per tooth |
219 |
80 |
$11K |
| D1206 |
Topical application of fluoride varnish |
361 |
353 |
$11K |
| D1110 |
Prophylaxis - adult |
93 |
91 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
19 |
$5K |
| D0330 |
Panoramic radiographic image |
67 |
64 |
$5K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
15 |
$5K |
| D0272 |
Bitewings - two radiographic images |
113 |
111 |
$4K |
| D0274 |
Bitewings - four radiographic images |
77 |
75 |
$4K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
17 |
12 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
14 |
13 |
$277.68 |
| D0603 |
|
360 |
352 |
$0.00 |