| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
493 |
383 |
$9K |
| D1110 |
Prophylaxis - adult |
325 |
241 |
$8K |
| D1120 |
Prophylaxis - child |
392 |
292 |
$8K |
| D1206 |
Topical application of fluoride varnish |
569 |
427 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
212 |
150 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
73 |
40 |
$6K |
| D0274 |
Bitewings - four radiographic images |
74 |
64 |
$2K |
| D0272 |
Bitewings - two radiographic images |
116 |
80 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
104 |
79 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
16 |
12 |
$982.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
12 |
$398.28 |
| D0230 |
Intraoral - periapical each additional radiographic image |
26 |
12 |
$230.18 |