| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
613 |
571 |
$10K |
| D1110 |
Prophylaxis - adult |
198 |
191 |
$7K |
| D1120 |
Prophylaxis - child |
257 |
231 |
$6K |
| D1206 |
Topical application of fluoride varnish |
250 |
223 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
217 |
211 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
15 |
$2K |
| D0272 |
Bitewings - two radiographic images |
76 |
73 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$459.60 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
14 |
$345.71 |
| D0220 |
Intraoral - periapical first radiographic image |
25 |
24 |
$230.00 |