| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
802 |
721 |
$20K |
| D1206 |
Topical application of fluoride varnish |
1,031 |
925 |
$19K |
| D1120 |
Prophylaxis - child |
741 |
664 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
260 |
97 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
318 |
269 |
$11K |
| D1110 |
Prophylaxis - adult |
205 |
179 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
774 |
644 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
78 |
50 |
$4K |
| D0272 |
Bitewings - two radiographic images |
168 |
127 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
582 |
488 |
$1K |
| D0274 |
Bitewings - four radiographic images |
92 |
66 |
$916.68 |
| D1208 |
Topical application of fluoride, excluding varnish |
66 |
62 |
$761.99 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$331.20 |