| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
278 |
271 |
$10K |
| D0120 |
Periodic oral evaluation - established patient |
126 |
119 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
101 |
95 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
69 |
39 |
$5K |
| D1110 |
Prophylaxis - adult |
57 |
49 |
$4K |
| D0210 |
Intraoral - complete series of radiographic images |
13 |
13 |
$3K |
| D1206 |
Topical application of fluoride varnish |
387 |
371 |
$797.22 |
| D1351 |
Sealant - per tooth |
73 |
12 |
$643.70 |
| D0272 |
Bitewings - two radiographic images |
44 |
41 |
$32.12 |
| D1330 |
|
337 |
323 |
$0.00 |
| D0191 |
|
132 |
131 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
31 |
31 |
$0.00 |