| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
838 |
833 |
$23K |
| D1110 |
Prophylaxis - adult |
550 |
546 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
247 |
172 |
$20K |
| D1120 |
Prophylaxis - child |
383 |
381 |
$12K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
133 |
102 |
$11K |
| D0274 |
Bitewings - four radiographic images |
284 |
281 |
$8K |
| D1206 |
Topical application of fluoride varnish |
388 |
386 |
$7K |
| D0330 |
Panoramic radiographic image |
113 |
112 |
$4K |
| D0601 |
|
407 |
405 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
42 |
$3K |
| D1330 |
|
404 |
402 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
39 |
38 |
$1K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$196.00 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
18 |
$144.00 |