| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,284 |
1,240 |
$51K |
| D0120 |
Periodic oral evaluation - established patient |
1,323 |
1,284 |
$36K |
| D1208 |
Topical application of fluoride, excluding varnish |
576 |
563 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
41 |
27 |
$3K |
| D0272 |
Bitewings - two radiographic images |
217 |
210 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
283 |
275 |
$2K |
| D0274 |
Bitewings - four radiographic images |
78 |
72 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
197 |
189 |
$744.80 |
| D0210 |
Intraoral - complete series of radiographic images |
54 |
52 |
$731.90 |
| D0330 |
Panoramic radiographic image |
13 |
13 |
$271.20 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$210.60 |