| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,238 |
4,168 |
$101K |
| D1110 |
Prophylaxis - adult |
2,255 |
2,217 |
$93K |
| D1120 |
Prophylaxis - child |
2,529 |
2,473 |
$83K |
| D1208 |
Topical application of fluoride, excluding varnish |
4,020 |
3,938 |
$81K |
| D0330 |
Panoramic radiographic image |
1,290 |
1,261 |
$45K |
| D0274 |
Bitewings - four radiographic images |
1,783 |
1,747 |
$44K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
629 |
456 |
$36K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
409 |
272 |
$29K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
532 |
509 |
$14K |
| D0272 |
Bitewings - two radiographic images |
677 |
659 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
645 |
623 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
97 |
97 |
$2K |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$570.90 |
| D0230 |
Intraoral - periapical each additional radiographic image |
21 |
12 |
$197.00 |