| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
865 |
838 |
$24K |
| D1120 |
Prophylaxis - child |
451 |
434 |
$16K |
| D1351 |
Sealant - per tooth |
590 |
108 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
889 |
858 |
$13K |
| D0274 |
Bitewings - four radiographic images |
353 |
328 |
$10K |
| D1110 |
Prophylaxis - adult |
174 |
170 |
$9K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
63 |
32 |
$5K |
| D0272 |
Bitewings - two radiographic images |
30 |
29 |
$675.68 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$452.10 |
| D0603 |
|
913 |
891 |
$0.00 |