| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
442 |
417 |
$11K |
| D1120 |
Prophylaxis - child |
234 |
220 |
$8K |
| D1110 |
Prophylaxis - adult |
144 |
139 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
431 |
409 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
52 |
30 |
$5K |
| D0274 |
Bitewings - four radiographic images |
159 |
150 |
$5K |
| D0272 |
Bitewings - two radiographic images |
191 |
180 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
265 |
240 |
$3K |
| D1351 |
Sealant - per tooth |
96 |
29 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
232 |
216 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
24 |
13 |
$1K |
| D0601 |
|
290 |
281 |
$0.00 |
| D0602 |
|
12 |
12 |
$0.00 |
| D0603 |
|
98 |
96 |
$0.00 |