| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
449 |
447 |
$29K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
392 |
168 |
$26K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
380 |
200 |
$20K |
| D1120 |
Prophylaxis - child |
638 |
634 |
$18K |
| D1351 |
Sealant - per tooth |
458 |
129 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
2,187 |
544 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
213 |
213 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
95 |
94 |
$4K |
| D0220 |
Intraoral - periapical first radiographic image |
202 |
202 |
$2K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
57 |
56 |
$2K |
| D1206 |
Topical application of fluoride varnish |
181 |
181 |
$2K |
| D0272 |
Bitewings - two radiographic images |
157 |
156 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$1K |
| D1208 |
Topical application of fluoride, excluding varnish |
112 |
112 |
$1K |
| D0274 |
Bitewings - four radiographic images |
36 |
36 |
$734.40 |