| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
445 |
372 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
498 |
411 |
$11K |
| D1208 |
Topical application of fluoride, excluding varnish |
437 |
365 |
$9K |
| D1351 |
Sealant - per tooth |
87 |
54 |
$6K |
| D0274 |
Bitewings - four radiographic images |
304 |
257 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
121 |
111 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
176 |
166 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
42 |
26 |
$2K |
| D1110 |
Prophylaxis - adult |
43 |
43 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
256 |
231 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
49 |
47 |
$315.40 |
| D1999 |
|
147 |
134 |
$0.00 |