| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,103 |
1,103 |
$26K |
| D1110 |
Prophylaxis - adult |
278 |
278 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
806 |
788 |
$12K |
| D0274 |
Bitewings - four radiographic images |
335 |
335 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
78 |
62 |
$8K |
| D1120 |
Prophylaxis - child |
211 |
211 |
$8K |
| D0230 |
Intraoral - periapical each additional radiographic image |
456 |
454 |
$6K |
| D0140 |
Limited oral evaluation - problem focused |
113 |
112 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
120 |
120 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
14 |
$1K |
| D0330 |
Panoramic radiographic image |
26 |
26 |
$1K |
| D1206 |
Topical application of fluoride varnish |
28 |
28 |
$745.50 |