| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
754 |
717 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
827 |
790 |
$11K |
| D1110 |
Prophylaxis - adult |
200 |
189 |
$9K |
| D1120 |
Prophylaxis - child |
290 |
268 |
$9K |
| D0220 |
Intraoral - periapical first radiographic image |
721 |
689 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
692 |
657 |
$7K |
| D0274 |
Bitewings - four radiographic images |
186 |
173 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
58 |
33 |
$5K |
| D0272 |
Bitewings - two radiographic images |
221 |
202 |
$5K |
| D1351 |
Sealant - per tooth |
157 |
46 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
55 |
28 |
$3K |
| D0603 |
|
626 |
615 |
$0.00 |
| D0602 |
|
41 |
41 |
$0.00 |
| D0601 |
|
90 |
80 |
$0.00 |