| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
3,748 |
3,592 |
$148K |
| D0120 |
Periodic oral evaluation - established patient |
3,862 |
3,704 |
$105K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
1,189 |
896 |
$92K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,054 |
2,946 |
$77K |
| D0274 |
Bitewings - four radiographic images |
1,088 |
1,026 |
$19K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
147 |
117 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
367 |
339 |
$2K |
| D0272 |
Bitewings - two radiographic images |
154 |
146 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
22 |
16 |
$1K |
| D1206 |
Topical application of fluoride varnish |
31 |
31 |
$728.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$191.20 |
| D0190 |
|
20 |
20 |
$0.00 |