| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
2,128 |
2,126 |
$60K |
| D1110 |
Prophylaxis - adult |
1,163 |
1,159 |
$45K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
491 |
220 |
$34K |
| D1120 |
Prophylaxis - child |
829 |
829 |
$26K |
| D0274 |
Bitewings - four radiographic images |
1,338 |
1,334 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
217 |
103 |
$14K |
| D0330 |
Panoramic radiographic image |
358 |
357 |
$14K |
| D0220 |
Intraoral - periapical first radiographic image |
2,675 |
2,628 |
$13K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,228 |
2,186 |
$13K |
| D1208 |
Topical application of fluoride, excluding varnish |
656 |
656 |
$10K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
257 |
257 |
$9K |
| D1206 |
Topical application of fluoride varnish |
149 |
149 |
$4K |
| D4341 |
|
34 |
12 |
$2K |
| D0272 |
Bitewings - two radiographic images |
87 |
87 |
$696.00 |
| D0140 |
Limited oral evaluation - problem focused |
28 |
28 |
$336.00 |
| D1330 |
|
527 |
502 |
$0.00 |