| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,210 |
1,210 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
472 |
247 |
$29K |
| D0274 |
Bitewings - four radiographic images |
645 |
645 |
$28K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,736 |
995 |
$21K |
| D1120 |
Prophylaxis - child |
598 |
598 |
$20K |
| D0220 |
Intraoral - periapical first radiographic image |
1,244 |
1,227 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
344 |
178 |
$19K |
| D1110 |
Prophylaxis - adult |
279 |
279 |
$14K |
| D1208 |
Topical application of fluoride, excluding varnish |
442 |
442 |
$4K |
| D1206 |
Topical application of fluoride varnish |
197 |
197 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
68 |
67 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
31 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
13 |
13 |
$488.80 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$312.00 |