| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
604 |
539 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,455 |
637 |
$13K |
| D1120 |
Prophylaxis - child |
421 |
378 |
$12K |
| D1208 |
Topical application of fluoride, excluding varnish |
641 |
584 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
759 |
665 |
$8K |
| D1110 |
Prophylaxis - adult |
141 |
119 |
$6K |
| D0274 |
Bitewings - four radiographic images |
234 |
203 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
68 |
33 |
$5K |
| D0272 |
Bitewings - two radiographic images |
237 |
218 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
13 |
$2K |
| D1351 |
Sealant - per tooth |
70 |
13 |
$2K |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$829.14 |
| D1206 |
Topical application of fluoride varnish |
15 |
15 |
$191.10 |
| D0602 |
|
607 |
539 |
$0.00 |
| D0603 |
|
177 |
142 |
$0.00 |
| D0601 |
|
35 |
33 |
$0.00 |