| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
664 |
625 |
$17K |
| D0274 |
Bitewings - four radiographic images |
1,091 |
1,038 |
$16K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
165 |
129 |
$15K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
113 |
97 |
$12K |
| D1120 |
Prophylaxis - child |
263 |
248 |
$10K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
51 |
46 |
$7K |
| D1110 |
Prophylaxis - adult |
153 |
149 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
228 |
228 |
$5K |
| D0140 |
Limited oral evaluation - problem focused |
288 |
255 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
253 |
237 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
62 |
50 |
$1K |
| D1206 |
Topical application of fluoride varnish |
41 |
41 |
$1K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$171.16 |