| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,177 |
2,121 |
$48K |
| D1110 |
Prophylaxis - adult |
1,535 |
1,472 |
$41K |
| D1120 |
Prophylaxis - child |
925 |
923 |
$37K |
| D0274 |
Bitewings - four radiographic images |
1,254 |
1,226 |
$35K |
| D0140 |
Limited oral evaluation - problem focused |
1,241 |
1,202 |
$32K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
395 |
180 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
661 |
661 |
$17K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
85 |
42 |
$6K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
59 |
41 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
302 |
289 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
217 |
164 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
25 |
25 |
$1K |
| D1206 |
Topical application of fluoride varnish |
33 |
32 |
$881.02 |