| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
3,144 |
435 |
$14K |
| D0120 |
Periodic oral evaluation - established patient |
110 |
108 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
98 |
98 |
$6K |
| D1120 |
Prophylaxis - child |
144 |
142 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
370 |
363 |
$5K |
| D1351 |
Sealant - per tooth |
187 |
39 |
$4K |
| D0272 |
Bitewings - two radiographic images |
318 |
316 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
23 |
13 |
$1K |
| D9430 |
|
12 |
12 |
$384.00 |