| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
322 |
299 |
$103.89 |
| D0230 |
Intraoral - periapical each additional radiographic image |
658 |
169 |
$92.30 |
| D1208 |
Topical application of fluoride, excluding varnish |
401 |
371 |
$45.03 |
| D0120 |
Periodic oral evaluation - established patient |
308 |
283 |
$43.88 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
70 |
65 |
$30.02 |
| D0220 |
Intraoral - periapical first radiographic image |
211 |
192 |
$23.08 |
| D1110 |
Prophylaxis - adult |
59 |
54 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
91 |
86 |
$0.00 |
| D0330 |
Panoramic radiographic image |
35 |
33 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
77 |
40 |
$0.00 |
| D0272 |
Bitewings - two radiographic images |
58 |
56 |
$0.00 |