| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,976 |
1,562 |
$39K |
| D1110 |
Prophylaxis - adult |
1,063 |
894 |
$38K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
486 |
238 |
$24K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,260 |
962 |
$14K |
| D1120 |
Prophylaxis - child |
825 |
592 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
230 |
119 |
$10K |
| D0220 |
Intraoral - periapical first radiographic image |
1,034 |
840 |
$8K |
| D0274 |
Bitewings - four radiographic images |
655 |
540 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
259 |
191 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
774 |
592 |
$1K |
| D0210 |
Intraoral - complete series of radiographic images |
58 |
29 |
$991.76 |
| D0330 |
Panoramic radiographic image |
26 |
25 |
$922.53 |
| D0140 |
Limited oral evaluation - problem focused |
22 |
15 |
$277.39 |