| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0274 |
Bitewings - four radiographic images |
1,532 |
1,532 |
$66K |
| D0120 |
Periodic oral evaluation - established patient |
1,643 |
1,643 |
$61K |
| D1110 |
Prophylaxis - adult |
461 |
461 |
$23K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,691 |
1,691 |
$22K |
| D1120 |
Prophylaxis - child |
602 |
602 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
220 |
112 |
$18K |
| D0220 |
Intraoral - periapical first radiographic image |
201 |
200 |
$3K |
| D0330 |
Panoramic radiographic image |
38 |
38 |
$3K |
| D0230 |
Intraoral - periapical each additional radiographic image |
213 |
54 |
$3K |
| D1351 |
Sealant - per tooth |
40 |
12 |
$2K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
38 |
38 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
19 |
13 |
$1K |
| D0272 |
Bitewings - two radiographic images |
24 |
24 |
$624.00 |