| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,091 |
1,566 |
$41K |
| D1110 |
Prophylaxis - adult |
1,268 |
935 |
$36K |
| D1120 |
Prophylaxis - child |
815 |
651 |
$18K |
| D1208 |
Topical application of fluoride, excluding varnish |
970 |
865 |
$15K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,478 |
726 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
1,161 |
866 |
$13K |
| D0274 |
Bitewings - four radiographic images |
479 |
353 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
69 |
29 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
72 |
26 |
$3K |
| D0272 |
Bitewings - two radiographic images |
166 |
150 |
$3K |
| D1206 |
Topical application of fluoride varnish |
298 |
148 |
$2K |
| D0330 |
Panoramic radiographic image |
46 |
43 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
18 |
15 |
$722.70 |
| D0140 |
Limited oral evaluation - problem focused |
16 |
12 |
$472.32 |