| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
740 |
670 |
$28K |
| D0120 |
Periodic oral evaluation - established patient |
1,209 |
1,105 |
$21K |
| D1206 |
Topical application of fluoride varnish |
870 |
801 |
$12K |
| D1120 |
Prophylaxis - child |
506 |
461 |
$10K |
| D0274 |
Bitewings - four radiographic images |
86 |
73 |
$3K |
| D1351 |
Sealant - per tooth |
379 |
70 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
45 |
27 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
85 |
68 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
67 |
65 |
$979.85 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
72 |
69 |
$692.25 |
| D9920 |
|
197 |
173 |
$46.75 |
| D1999 |
|
58 |
41 |
$0.00 |