| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
1,166 |
375 |
$12K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
251 |
245 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
457 |
453 |
$6K |
| D1120 |
Prophylaxis - child |
151 |
151 |
$5K |
| D1351 |
Sealant - per tooth |
174 |
33 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
45 |
12 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
394 |
385 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
124 |
124 |
$3K |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$2K |
| D1110 |
Prophylaxis - adult |
27 |
27 |
$1K |
| D0274 |
Bitewings - four radiographic images |
42 |
42 |
$1K |
| D0603 |
|
625 |
616 |
$36.17 |