| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
482 |
394 |
$159K |
| D1120 |
Prophylaxis - child |
210 |
193 |
$40K |
| D0140 |
Limited oral evaluation - problem focused |
59 |
53 |
$39K |
| D0220 |
Intraoral - periapical first radiographic image |
279 |
213 |
$37K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
114 |
36 |
$19K |
| D0274 |
Bitewings - four radiographic images |
309 |
225 |
$15K |
| D1206 |
Topical application of fluoride varnish |
347 |
300 |
$14K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
27 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
49 |
24 |
$11K |
| D1110 |
Prophylaxis - adult |
54 |
40 |
$10K |
| D0330 |
Panoramic radiographic image |
47 |
28 |
$794.88 |
| D1208 |
Topical application of fluoride, excluding varnish |
17 |
13 |
$682.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
178 |
87 |
$105.85 |