| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0220 |
Intraoral - periapical first radiographic image |
435 |
431 |
$9K |
| D1206 |
Topical application of fluoride varnish |
252 |
195 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
122 |
122 |
$8K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
51 |
43 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
305 |
268 |
$7K |
| D1120 |
Prophylaxis - child |
125 |
108 |
$5K |
| D0120 |
Periodic oral evaluation - established patient |
146 |
129 |
$5K |
| D0274 |
Bitewings - four radiographic images |
92 |
91 |
$4K |
| D0272 |
Bitewings - two radiographic images |
100 |
100 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
40 |
39 |
$3K |
| D1351 |
Sealant - per tooth |
98 |
33 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
21 |
15 |
$2K |
| D1110 |
Prophylaxis - adult |
28 |
27 |
$2K |
| D9996 |
|
49 |
49 |
$543.00 |