| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
4,602 |
4,602 |
$128K |
| D1120 |
Prophylaxis - child |
2,886 |
2,886 |
$75K |
| D1110 |
Prophylaxis - adult |
1,934 |
1,934 |
$67K |
| D1206 |
Topical application of fluoride varnish |
3,198 |
3,198 |
$58K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
274 |
144 |
$28K |
| D0274 |
Bitewings - four radiographic images |
885 |
885 |
$22K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,933 |
1,933 |
$15K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
70 |
50 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
161 |
161 |
$9K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
208 |
208 |
$7K |
| D0140 |
Limited oral evaluation - problem focused |
41 |
41 |
$1K |
| D0220 |
Intraoral - periapical first radiographic image |
55 |
55 |
$585.96 |
| D0272 |
Bitewings - two radiographic images |
14 |
14 |
$265.02 |