| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
461 |
460 |
$12K |
| D1120 |
Prophylaxis - child |
235 |
234 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
553 |
552 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
547 |
534 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
62 |
24 |
$6K |
| D0230 |
Intraoral - periapical each additional radiographic image |
513 |
496 |
$5K |
| D1351 |
Sealant - per tooth |
180 |
43 |
$5K |
| D0272 |
Bitewings - two radiographic images |
206 |
206 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
12 |
12 |
$658.56 |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$445.32 |
| D0603 |
|
118 |
102 |
$0.00 |
| D0602 |
|
369 |
365 |
$0.00 |