| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
685 |
685 |
$38K |
| D1120 |
Prophylaxis - child |
780 |
780 |
$32K |
| D0120 |
Periodic oral evaluation - established patient |
584 |
584 |
$17K |
| D1351 |
Sealant - per tooth |
491 |
136 |
$17K |
| D1206 |
Topical application of fluoride varnish |
570 |
562 |
$13K |
| D0274 |
Bitewings - four radiographic images |
135 |
135 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
243 |
243 |
$3K |
| D0272 |
Bitewings - two radiographic images |
98 |
98 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
55 |
55 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$194.00 |
| D1999 |
|
23 |
23 |
$0.00 |
| D0603 |
|
47 |
46 |
$0.00 |