| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
981 |
977 |
$42K |
| D1110 |
Prophylaxis - adult |
399 |
398 |
$24K |
| D0330 |
Panoramic radiographic image |
147 |
147 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
133 |
66 |
$9K |
| D1206 |
Topical application of fluoride varnish |
1,464 |
1,457 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
1,478 |
1,473 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
568 |
403 |
$5K |
| D1330 |
|
1,325 |
1,320 |
$878.04 |
| D0220 |
Intraoral - periapical first radiographic image |
545 |
530 |
$587.00 |
| D0603 |
|
1,022 |
1,021 |
$565.00 |
| D0274 |
Bitewings - four radiographic images |
158 |
158 |
$281.00 |
| D0272 |
Bitewings - two radiographic images |
142 |
140 |
$234.00 |