| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
409 |
404 |
$11K |
| D1110 |
Prophylaxis - adult |
221 |
221 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
84 |
45 |
$5K |
| D1120 |
Prophylaxis - child |
142 |
136 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
192 |
185 |
$3K |
| D0274 |
Bitewings - four radiographic images |
185 |
185 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
271 |
266 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$832.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
120 |
120 |
$606.00 |
| D0140 |
Limited oral evaluation - problem focused |
26 |
25 |
$593.00 |
| D1206 |
Topical application of fluoride varnish |
13 |
13 |
$112.19 |