| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
748 |
283 |
$7K |
| D1120 |
Prophylaxis - child |
190 |
190 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
295 |
295 |
$6K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
246 |
244 |
$5K |
| D1110 |
Prophylaxis - adult |
100 |
99 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
220 |
219 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
38 |
24 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
338 |
336 |
$3K |
| D1351 |
Sealant - per tooth |
90 |
24 |
$3K |
| D0274 |
Bitewings - four radiographic images |
87 |
87 |
$2K |
| D0272 |
Bitewings - two radiographic images |
62 |
62 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
15 |
15 |
$347.62 |