| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
716 |
673 |
$15K |
| D1110 |
Prophylaxis - adult |
504 |
464 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
617 |
477 |
$13K |
| D0274 |
Bitewings - four radiographic images |
343 |
313 |
$9K |
| D1208 |
Topical application of fluoride, excluding varnish |
435 |
408 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
499 |
411 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
72 |
39 |
$5K |
| D1120 |
Prophylaxis - child |
80 |
77 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
207 |
102 |
$2K |
| D0330 |
Panoramic radiographic image |
34 |
31 |
$682.08 |
| D0210 |
Intraoral - complete series of radiographic images |
12 |
12 |
$525.20 |