| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
1,987 |
1,662 |
$40K |
| D1110 |
Prophylaxis - adult |
880 |
784 |
$28K |
| D1206 |
Topical application of fluoride varnish |
1,613 |
1,443 |
$22K |
| D0220 |
Intraoral - periapical first radiographic image |
1,264 |
1,130 |
$17K |
| D1120 |
Prophylaxis - child |
637 |
592 |
$16K |
| D0274 |
Bitewings - four radiographic images |
364 |
341 |
$11K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
274 |
257 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
88 |
43 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
752 |
643 |
$9K |
| D0330 |
Panoramic radiographic image |
140 |
135 |
$7K |
| D0250 |
|
209 |
202 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
26 |
13 |
$2K |
| D4355 |
|
27 |
27 |
$2K |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$243.84 |