| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,323 |
1,323 |
$29K |
| D1110 |
Prophylaxis - adult |
864 |
864 |
$28K |
| D1120 |
Prophylaxis - child |
706 |
706 |
$18K |
| D1206 |
Topical application of fluoride varnish |
624 |
589 |
$13K |
| D0274 |
Bitewings - four radiographic images |
823 |
821 |
$11K |
| D0210 |
Intraoral - complete series of radiographic images |
204 |
204 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
400 |
400 |
$9K |
| D0140 |
Limited oral evaluation - problem focused |
196 |
193 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
31 |
$4K |
| D0330 |
Panoramic radiographic image |
440 |
440 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
38 |
25 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
238 |
228 |
$1K |
| D0272 |
Bitewings - two radiographic images |
98 |
98 |
$1K |
| D0230 |
Intraoral - periapical each additional radiographic image |
35 |
28 |
$139.09 |