| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
370 |
340 |
$12K |
| D0120 |
Periodic oral evaluation - established patient |
333 |
311 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
170 |
74 |
$7K |
| D1206 |
Topical application of fluoride varnish |
287 |
260 |
$6K |
| D0274 |
Bitewings - four radiographic images |
162 |
150 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
77 |
31 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
105 |
97 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
303 |
276 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
268 |
228 |
$855.00 |
| D1110 |
Prophylaxis - adult |
29 |
28 |
$820.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
63 |
60 |
$754.00 |
| D0272 |
Bitewings - two radiographic images |
70 |
64 |
$479.40 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
26 |
$405.00 |