| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
787 |
785 |
$12K |
| D1110 |
Prophylaxis - adult |
577 |
577 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
189 |
113 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
141 |
104 |
$5K |
| D2750 |
|
14 |
12 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
112 |
112 |
$3K |
| D1120 |
Prophylaxis - child |
168 |
168 |
$2K |
| D1206 |
Topical application of fluoride varnish |
120 |
120 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
470 |
441 |
$2K |
| D0210 |
Intraoral - complete series of radiographic images |
63 |
63 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
238 |
228 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
62 |
62 |
$620.00 |
| D0274 |
Bitewings - four radiographic images |
29 |
29 |
$261.00 |
| D0330 |
Panoramic radiographic image |
14 |
14 |
$220.50 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$168.00 |