| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,818 |
1,760 |
$46K |
| D1110 |
Prophylaxis - adult |
1,112 |
1,074 |
$42K |
| D0220 |
Intraoral - periapical first radiographic image |
1,703 |
1,576 |
$25K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,155 |
1,176 |
$24K |
| D1120 |
Prophylaxis - child |
834 |
805 |
$23K |
| D0274 |
Bitewings - four radiographic images |
723 |
696 |
$21K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,196 |
1,148 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
147 |
92 |
$16K |
| D0330 |
Panoramic radiographic image |
277 |
271 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
345 |
319 |
$13K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
79 |
54 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
148 |
140 |
$5K |
| D0272 |
Bitewings - two radiographic images |
152 |
146 |
$3K |
| D1351 |
Sealant - per tooth |
65 |
16 |
$2K |
| D1206 |
Topical application of fluoride varnish |
35 |
31 |
$486.62 |