| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0120 |
Periodic oral evaluation - established patient |
794 |
774 |
$16K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
516 |
501 |
$14K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
317 |
42 |
$14K |
| D1120 |
Prophylaxis - child |
517 |
503 |
$8K |
| D1208 |
Topical application of fluoride, excluding varnish |
552 |
536 |
$7K |
| D0210 |
Intraoral - complete series of radiographic images |
433 |
421 |
$6K |
| D1206 |
Topical application of fluoride varnish |
47 |
47 |
$1K |
| D0999 |
Unspecified diagnostic procedure, by report |
13 |
13 |
$780.00 |
| D1999 |
|
496 |
441 |
$780.00 |
| D1351 |
Sealant - per tooth |
73 |
16 |
$549.00 |
| D4341 |
|
70 |
15 |
$480.00 |
| D0350 |
|
58 |
15 |
$39.60 |
| D0220 |
Intraoral - periapical first radiographic image |
16 |
13 |
$34.00 |
| D4921 |
|
70 |
15 |
$0.00 |