| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
299 |
297 |
$19K |
| D1120 |
Prophylaxis - child |
417 |
416 |
$14K |
| D1110 |
Prophylaxis - adult |
234 |
234 |
$11K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
94 |
72 |
$11K |
| D1206 |
Topical application of fluoride varnish |
533 |
530 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
375 |
375 |
$9K |
| D0330 |
Panoramic radiographic image |
109 |
109 |
$6K |
| D0272 |
Bitewings - two radiographic images |
313 |
313 |
$5K |
| D0274 |
Bitewings - four radiographic images |
189 |
188 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
188 |
179 |
$4K |
| D1351 |
Sealant - per tooth |
181 |
58 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
45 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
45 |
29 |
$1K |
| D7140 |
Extraction, erupted tooth or exposed root |
22 |
16 |
$1K |
| D0140 |
Limited oral evaluation - problem focused |
18 |
18 |
$429.00 |