| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,228 |
1,222 |
$47K |
| D1120 |
Prophylaxis - child |
540 |
540 |
$20K |
| D1208 |
Topical application of fluoride, excluding varnish |
534 |
533 |
$14K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
273 |
272 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,781 |
1,363 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,733 |
1,669 |
$9K |
| D0274 |
Bitewings - four radiographic images |
796 |
796 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
116 |
65 |
$5K |
| D1110 |
Prophylaxis - adult |
108 |
108 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
158 |
157 |
$3K |
| D1999 |
|
1,031 |
1,016 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
13 |
$1K |
| D0999 |
Unspecified diagnostic procedure, by report |
12 |
12 |
$720.00 |
| D0330 |
Panoramic radiographic image |
108 |
108 |
$191.50 |
| D0350 |
|
174 |
170 |
$7.20 |
| D1330 |
|
13 |
13 |
$0.00 |