| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,887 |
1,884 |
$49K |
| D1110 |
Prophylaxis - adult |
1,063 |
1,061 |
$49K |
| D1120 |
Prophylaxis - child |
943 |
942 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
441 |
319 |
$30K |
| D1208 |
Topical application of fluoride, excluding varnish |
589 |
589 |
$15K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
237 |
179 |
$13K |
| D0140 |
Limited oral evaluation - problem focused |
286 |
279 |
$12K |
| D1206 |
Topical application of fluoride varnish |
326 |
325 |
$11K |
| D0274 |
Bitewings - four radiographic images |
773 |
773 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
15 |
15 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
74 |
65 |
$6K |
| D0272 |
Bitewings - two radiographic images |
309 |
309 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
94 |
94 |
$2K |
| D0220 |
Intraoral - periapical first radiographic image |
383 |
381 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
143 |
143 |
$963.45 |
| D0270 |
|
150 |
149 |
$787.50 |