| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
322 |
316 |
$17K |
| D0120 |
Periodic oral evaluation - established patient |
452 |
441 |
$12K |
| D1120 |
Prophylaxis - child |
328 |
324 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
118 |
63 |
$9K |
| D0274 |
Bitewings - four radiographic images |
251 |
244 |
$8K |
| D1206 |
Topical application of fluoride varnish |
434 |
429 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
59 |
31 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
373 |
363 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
384 |
344 |
$4K |
| D0272 |
Bitewings - two radiographic images |
141 |
139 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
140 |
138 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$226.88 |
| D0601 |
|
18 |
18 |
$0.00 |
| D0602 |
|
308 |
303 |
$0.00 |
| D0603 |
|
110 |
108 |
$0.00 |