| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
2,302 |
2,214 |
$91K |
| D0120 |
Periodic oral evaluation - established patient |
2,442 |
2,339 |
$64K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,201 |
1,160 |
$30K |
| D0274 |
Bitewings - four radiographic images |
956 |
926 |
$16K |
| D0220 |
Intraoral - periapical first radiographic image |
2,521 |
2,373 |
$14K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,165 |
2,034 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
211 |
203 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
290 |
267 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
49 |
27 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
39 |
30 |
$2K |
| D1110 |
Prophylaxis - adult |
62 |
59 |
$2K |
| D0272 |
Bitewings - two radiographic images |
130 |
123 |
$1K |
| D1206 |
Topical application of fluoride varnish |
26 |
26 |
$650.00 |
| D0270 |
|
58 |
56 |
$285.60 |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$248.60 |