| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1206 |
Topical application of fluoride varnish |
642 |
599 |
$0.00 |
| D0120 |
Periodic oral evaluation - established patient |
385 |
363 |
$0.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,095 |
548 |
$0.00 |
| D1330 |
|
470 |
409 |
$0.00 |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
15 |
12 |
$0.00 |
| D0603 |
|
25 |
25 |
$0.00 |
| D4999 |
|
16 |
12 |
$0.00 |
| D0220 |
Intraoral - periapical first radiographic image |
811 |
738 |
$0.00 |
| D1110 |
Prophylaxis - adult |
449 |
415 |
$0.00 |
| D0274 |
Bitewings - four radiographic images |
376 |
351 |
$0.00 |
| D1120 |
Prophylaxis - child |
44 |
40 |
$0.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
14 |
12 |
$0.00 |