| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,781 |
1,780 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
735 |
539 |
$29K |
| D1110 |
Prophylaxis - adult |
1,167 |
1,165 |
$23K |
| D1120 |
Prophylaxis - child |
639 |
639 |
$13K |
| D0274 |
Bitewings - four radiographic images |
1,271 |
1,270 |
$11K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,357 |
1,335 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
408 |
407 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
202 |
163 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,832 |
1,825 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
470 |
470 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
33 |
33 |
$790.00 |
| D0272 |
Bitewings - two radiographic images |
160 |
160 |
$790.00 |
| D0270 |
|
162 |
162 |
$486.00 |
| D1206 |
Topical application of fluoride varnish |
33 |
33 |
$366.25 |