| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
1,159 |
358 |
$11K |
| D1120 |
Prophylaxis - child |
248 |
245 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
262 |
260 |
$7K |
| D1351 |
Sealant - per tooth |
266 |
44 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
75 |
26 |
$7K |
| D0145 |
Oral evaluation for a patient under three years of age |
39 |
39 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
358 |
355 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
387 |
372 |
$5K |
| D0274 |
Bitewings - four radiographic images |
121 |
121 |
$4K |
| D1110 |
Prophylaxis - adult |
60 |
60 |
$3K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
53 |
52 |
$2K |
| D0350 |
|
34 |
33 |
$588.16 |
| D0272 |
Bitewings - two radiographic images |
16 |
15 |
$350.70 |
| D0330 |
Panoramic radiographic image |
15 |
15 |
$85.83 |
| D0603 |
|
490 |
487 |
$0.00 |