| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,090 |
1,085 |
$32K |
| D1120 |
Prophylaxis - child |
663 |
660 |
$29K |
| D1206 |
Topical application of fluoride varnish |
474 |
472 |
$14K |
| D1110 |
Prophylaxis - adult |
309 |
306 |
$14K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
133 |
63 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
210 |
210 |
$5K |
| D0274 |
Bitewings - four radiographic images |
397 |
394 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
997 |
965 |
$4K |
| D0330 |
Panoramic radiographic image |
91 |
91 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
902 |
870 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
41 |
40 |
$370.00 |
| D1330 |
|
909 |
842 |
$0.00 |