| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,293 |
2,291 |
$83K |
| D0120 |
Periodic oral evaluation - established patient |
3,257 |
3,252 |
$81K |
| D1206 |
Topical application of fluoride varnish |
2,673 |
2,667 |
$58K |
| D1110 |
Prophylaxis - adult |
1,121 |
1,118 |
$53K |
| D0220 |
Intraoral - periapical first radiographic image |
1,175 |
1,126 |
$18K |
| D0272 |
Bitewings - two radiographic images |
509 |
509 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
82 |
52 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
709 |
620 |
$6K |
| D0274 |
Bitewings - four radiographic images |
108 |
107 |
$3K |
| D0330 |
Panoramic radiographic image |
40 |
40 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$1K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
27 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$480.00 |