| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1120 |
Prophylaxis - child |
1,184 |
1,049 |
$35K |
| D0120 |
Periodic oral evaluation - established patient |
1,354 |
1,205 |
$26K |
| D1206 |
Topical application of fluoride varnish |
1,613 |
1,433 |
$25K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
235 |
107 |
$15K |
| D0220 |
Intraoral - periapical first radiographic image |
1,440 |
1,264 |
$14K |
| D1110 |
Prophylaxis - adult |
339 |
306 |
$12K |
| D0272 |
Bitewings - two radiographic images |
895 |
781 |
$12K |
| D0230 |
Intraoral - periapical each additional radiographic image |
1,421 |
1,120 |
$11K |
| D0330 |
Panoramic radiographic image |
221 |
201 |
$9K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
92 |
43 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
231 |
200 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
118 |
114 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
72 |
67 |
$2K |
| D1208 |
Topical application of fluoride, excluding varnish |
113 |
109 |
$2K |
| D0240 |
|
45 |
45 |
$636.30 |
| D0274 |
Bitewings - four radiographic images |
15 |
15 |
$356.86 |