| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,119 |
1,111 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
811 |
479 |
$54K |
| D1120 |
Prophylaxis - child |
1,298 |
1,288 |
$47K |
| D0274 |
Bitewings - four radiographic images |
1,366 |
1,354 |
$29K |
| D1110 |
Prophylaxis - adult |
304 |
298 |
$27K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,287 |
1,277 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,061 |
1,162 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
125 |
122 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
38 |
38 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
36 |
12 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
18 |
16 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
83 |
82 |
$984.00 |