| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,140 |
1,135 |
$43K |
| D1120 |
Prophylaxis - child |
802 |
801 |
$26K |
| D1110 |
Prophylaxis - adult |
348 |
347 |
$16K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
163 |
92 |
$16K |
| D1206 |
Topical application of fluoride varnish |
508 |
501 |
$16K |
| D1208 |
Topical application of fluoride, excluding varnish |
529 |
529 |
$9K |
| D0272 |
Bitewings - two radiographic images |
385 |
381 |
$8K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
106 |
64 |
$8K |
| D0140 |
Limited oral evaluation - problem focused |
134 |
133 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
75 |
75 |
$3K |
| D0274 |
Bitewings - four radiographic images |
57 |
57 |
$2K |
| D0330 |
Panoramic radiographic image |
12 |
12 |
$600.00 |
| D0220 |
Intraoral - periapical first radiographic image |
12 |
12 |
$175.56 |