| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0230 |
Intraoral - periapical each additional radiographic image |
1,260 |
429 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
640 |
572 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
38 |
$8K |
| D1120 |
Prophylaxis - child |
202 |
202 |
$8K |
| D2930 |
Prefabricated stainless steel crown - primary tooth |
41 |
15 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
87 |
87 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
83 |
82 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
124 |
124 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
27 |
12 |
$3K |
| D0272 |
Bitewings - two radiographic images |
101 |
101 |
$2K |
| D0120 |
Periodic oral evaluation - established patient |
83 |
83 |
$2K |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$756.00 |
| D1206 |
Topical application of fluoride varnish |
14 |
14 |
$410.00 |