| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,619 |
1,384 |
$55K |
| D1110 |
Prophylaxis - adult |
810 |
695 |
$50K |
| D1120 |
Prophylaxis - child |
632 |
554 |
$28K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,026 |
893 |
$28K |
| D0220 |
Intraoral - periapical first radiographic image |
803 |
680 |
$16K |
| D0274 |
Bitewings - four radiographic images |
337 |
260 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
719 |
598 |
$13K |
| D1206 |
Topical application of fluoride varnish |
303 |
276 |
$9K |
| D0330 |
Panoramic radiographic image |
51 |
46 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
12 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
56 |
46 |
$3K |
| D0272 |
Bitewings - two radiographic images |
16 |
16 |
$585.60 |
| D0602 |
|
1,848 |
1,609 |
$0.00 |