| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
803 |
803 |
$29K |
| D1120 |
Prophylaxis - child |
694 |
694 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
985 |
985 |
$19K |
| D0274 |
Bitewings - four radiographic images |
525 |
525 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,010 |
1,008 |
$11K |
| D0330 |
Panoramic radiographic image |
203 |
203 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
956 |
905 |
$9K |
| D0272 |
Bitewings - two radiographic images |
251 |
251 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
158 |
158 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
55 |
52 |
$2K |
| D1110 |
Prophylaxis - adult |
28 |
28 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
14 |
12 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$970.63 |