| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
306 |
292 |
$77.04 |
| D0120 |
Periodic oral evaluation - established patient |
344 |
311 |
$51.09 |
| D0220 |
Intraoral - periapical first radiographic image |
407 |
377 |
$50.28 |
| D1208 |
Topical application of fluoride, excluding varnish |
393 |
374 |
$32.44 |
| D1330 |
|
487 |
461 |
$31.63 |
| D0230 |
Intraoral - periapical each additional radiographic image |
418 |
199 |
$19.46 |
| D0603 |
|
218 |
206 |
$17.00 |
| D0274 |
Bitewings - four radiographic images |
129 |
122 |
$0.00 |
| D1110 |
Prophylaxis - adult |
324 |
293 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
47 |
34 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
44 |
$0.00 |
| D1206 |
Topical application of fluoride varnish |
175 |
160 |
$0.00 |
| D0140 |
Limited oral evaluation - problem focused |
63 |
60 |
$0.00 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
31 |
30 |
$0.00 |
| D0602 |
|
13 |
12 |
$0.00 |