| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,830 |
2,732 |
$115K |
| D0120 |
Periodic oral evaluation - established patient |
2,815 |
2,715 |
$78K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,569 |
1,502 |
$40K |
| D8670 |
Periodic orthodontic treatment visit |
113 |
105 |
$25K |
| D0274 |
Bitewings - four radiographic images |
1,177 |
1,130 |
$20K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
26 |
25 |
$4K |
| D1351 |
Sealant - per tooth |
26 |
15 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
53 |
52 |
$906.36 |
| D0210 |
Intraoral - complete series of radiographic images |
39 |
28 |
$537.30 |
| D0220 |
Intraoral - periapical first radiographic image |
34 |
25 |
$179.20 |
| D1999 |
|
58 |
54 |
$0.00 |