| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,184 |
1,181 |
$35K |
| D1120 |
Prophylaxis - child |
705 |
704 |
$31K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
442 |
206 |
$30K |
| D1110 |
Prophylaxis - adult |
499 |
496 |
$21K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
304 |
155 |
$17K |
| D1208 |
Topical application of fluoride, excluding varnish |
591 |
589 |
$14K |
| D0330 |
Panoramic radiographic image |
263 |
263 |
$10K |
| D0274 |
Bitewings - four radiographic images |
634 |
629 |
$7K |
| D0220 |
Intraoral - periapical first radiographic image |
1,441 |
1,397 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,347 |
1,305 |
$4K |
| D1206 |
Topical application of fluoride varnish |
138 |
137 |
$4K |
| D0272 |
Bitewings - two radiographic images |
184 |
183 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
26 |
26 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
54 |
$643.00 |
| D1330 |
|
596 |
536 |
$0.00 |