| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,767 |
1,723 |
$281.75 |
| D0120 |
Periodic oral evaluation - established patient |
2,235 |
2,176 |
$223.16 |
| D1208 |
Topical application of fluoride, excluding varnish |
2,264 |
2,204 |
$192.55 |
| D0220 |
Intraoral - periapical first radiographic image |
1,227 |
1,200 |
$26.57 |
| D0272 |
Bitewings - two radiographic images |
862 |
827 |
$17.32 |
| D1206 |
Topical application of fluoride varnish |
123 |
123 |
$15.01 |
| D1110 |
Prophylaxis - adult |
200 |
187 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
45 |
43 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
683 |
632 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
17 |
$0.00 |
| D0603 |
|
30 |
30 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
30 |
$0.00 |
| D9248 |
|
14 |
13 |
$0.00 |
| D1351 |
Sealant - per tooth |
41 |
12 |
$0.00 |