| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,803 |
1,803 |
$36K |
| D1120 |
Prophylaxis - child |
1,112 |
1,111 |
$22K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
506 |
387 |
$20K |
| D1110 |
Prophylaxis - adult |
934 |
934 |
$19K |
| D0274 |
Bitewings - four radiographic images |
1,059 |
1,059 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,207 |
1,207 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
328 |
324 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,003 |
1,003 |
$6K |
| D0220 |
Intraoral - periapical first radiographic image |
1,457 |
1,453 |
$6K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
149 |
131 |
$5K |
| D0272 |
Bitewings - two radiographic images |
717 |
717 |
$4K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
179 |
179 |
$4K |
| D0330 |
Panoramic radiographic image |
133 |
133 |
$3K |
| D1351 |
Sealant - per tooth |
242 |
83 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
30 |
27 |
$1K |
| D0270 |
|
63 |
63 |
$189.00 |