| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
592 |
585 |
$23K |
| D1110 |
Prophylaxis - adult |
280 |
279 |
$20K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
346 |
93 |
$15K |
| D0120 |
Periodic oral evaluation - established patient |
465 |
460 |
$10K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,277 |
1,187 |
$10K |
| D1120 |
Prophylaxis - child |
246 |
244 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,036 |
1,024 |
$2K |
| D1351 |
Sealant - per tooth |
266 |
73 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
123 |
37 |
$1K |
| D1330 |
|
1,310 |
1,289 |
$788.59 |
| D0220 |
Intraoral - periapical first radiographic image |
1,243 |
1,227 |
$519.45 |
| D0274 |
Bitewings - four radiographic images |
815 |
806 |
$457.23 |
| D0272 |
Bitewings - two radiographic images |
29 |
28 |
$0.00 |