| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
1,149 |
593 |
$13K |
| D1120 |
Prophylaxis - child |
234 |
234 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
685 |
678 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
357 |
357 |
$7K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
494 |
490 |
$7K |
| D1110 |
Prophylaxis - adult |
129 |
127 |
$6K |
| D0120 |
Periodic oral evaluation - established patient |
200 |
200 |
$4K |
| D0274 |
Bitewings - four radiographic images |
131 |
131 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
34 |
20 |
$3K |
| D1351 |
Sealant - per tooth |
63 |
15 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
18 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
78 |
76 |
$1K |
| D0272 |
Bitewings - two radiographic images |
41 |
41 |
$826.15 |