| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
442 |
335 |
$8K |
| D1110 |
Prophylaxis - adult |
257 |
189 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
43 |
28 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
220 |
153 |
$3K |
| D1120 |
Prophylaxis - child |
55 |
39 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
97 |
54 |
$899.28 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
16 |
15 |
$719.70 |
| D0140 |
Limited oral evaluation - problem focused |
19 |
15 |
$618.76 |
| D0274 |
Bitewings - four radiographic images |
34 |
16 |
$493.22 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$246.54 |