| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
461 |
439 |
$24K |
| D0120 |
Periodic oral evaluation - established patient |
700 |
665 |
$19K |
| D0274 |
Bitewings - four radiographic images |
522 |
498 |
$17K |
| D9920 |
|
359 |
328 |
$16K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,227 |
780 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
767 |
734 |
$11K |
| D0220 |
Intraoral - periapical first radiographic image |
869 |
828 |
$10K |
| D1351 |
Sealant - per tooth |
120 |
12 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
27 |
25 |
$918.75 |
| D0603 |
|
983 |
948 |
$0.00 |
| D0602 |
|
18 |
18 |
$0.00 |