| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
977 |
932 |
$36K |
| D0120 |
Periodic oral evaluation - established patient |
1,368 |
1,290 |
$34K |
| D1110 |
Prophylaxis - adult |
334 |
303 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
523 |
485 |
$10K |
| D1208 |
Topical application of fluoride, excluding varnish |
392 |
380 |
$10K |
| D0274 |
Bitewings - four radiographic images |
620 |
565 |
$10K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
144 |
116 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,245 |
1,138 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,004 |
854 |
$4K |
| D1206 |
Topical application of fluoride varnish |
217 |
200 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
132 |
116 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
74 |
58 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
46 |
33 |
$2K |
| D0330 |
Panoramic radiographic image |
49 |
38 |
$680.82 |
| D0272 |
Bitewings - two radiographic images |
48 |
43 |
$440.85 |