| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
483 |
480 |
$11K |
| D1110 |
Prophylaxis - adult |
373 |
372 |
$10K |
| D0140 |
Limited oral evaluation - problem focused |
238 |
227 |
$7K |
| D1120 |
Prophylaxis - child |
114 |
114 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
319 |
275 |
$3K |
| D0274 |
Bitewings - four radiographic images |
110 |
109 |
$3K |
| D0272 |
Bitewings - two radiographic images |
153 |
150 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
28 |
16 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
13 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
42 |
$1K |
| D0330 |
Panoramic radiographic image |
16 |
15 |
$988.32 |
| D0150 |
Comprehensive oral evaluation - new or established patient |
12 |
12 |
$483.60 |