| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
340 |
300 |
$7K |
| D1110 |
Prophylaxis - adult |
233 |
194 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
204 |
151 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
387 |
318 |
$4K |
| D0274 |
Bitewings - four radiographic images |
228 |
174 |
$4K |
| D0330 |
Panoramic radiographic image |
178 |
136 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
320 |
215 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
24 |
14 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
29 |
12 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
28 |
12 |
$1K |
| D1120 |
Prophylaxis - child |
73 |
54 |
$1K |
| D4355 |
|
14 |
12 |
$692.44 |
| D1206 |
Topical application of fluoride varnish |
29 |
24 |
$394.32 |
| D1208 |
Topical application of fluoride, excluding varnish |
24 |
13 |
$63.04 |