| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
681 |
633 |
$16K |
| D1120 |
Prophylaxis - child |
434 |
407 |
$11K |
| D1206 |
Topical application of fluoride varnish |
661 |
616 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
107 |
58 |
$9K |
| D1110 |
Prophylaxis - adult |
248 |
228 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
526 |
478 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
495 |
400 |
$5K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
81 |
68 |
$3K |
| D0272 |
Bitewings - two radiographic images |
125 |
116 |
$2K |
| D1351 |
Sealant - per tooth |
77 |
14 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$675.45 |
| D0274 |
Bitewings - four radiographic images |
17 |
12 |
$241.00 |
| D1999 |
|
37 |
34 |
$0.00 |