| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
385 |
383 |
$18K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
157 |
92 |
$17K |
| D1110 |
Prophylaxis - adult |
319 |
319 |
$17K |
| D0140 |
Limited oral evaluation - problem focused |
384 |
379 |
$17K |
| D1351 |
Sealant - per tooth |
417 |
63 |
$12K |
| D0220 |
Intraoral - periapical first radiographic image |
572 |
565 |
$9K |
| D0210 |
Intraoral - complete series of radiographic images |
144 |
130 |
$9K |
| D2740 |
Crown - porcelain/ceramic |
19 |
12 |
$8K |
| D0330 |
Panoramic radiographic image |
116 |
116 |
$7K |
| D0230 |
Intraoral - periapical each additional radiographic image |
474 |
306 |
$4K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
51 |
26 |
$4K |
| D2950 |
|
31 |
27 |
$4K |
| D0274 |
Bitewings - four radiographic images |
104 |
104 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
63 |
63 |
$2K |
| D1206 |
Topical application of fluoride varnish |
12 |
12 |
$124.79 |