| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
260 |
246 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
190 |
187 |
$4K |
| D1120 |
Prophylaxis - child |
178 |
176 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
44 |
15 |
$2K |
| D1351 |
Sealant - per tooth |
119 |
25 |
$1K |
| D1110 |
Prophylaxis - adult |
31 |
29 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
31 |
17 |
$980.00 |
| D0274 |
Bitewings - four radiographic images |
108 |
99 |
$592.00 |
| D0220 |
Intraoral - periapical first radiographic image |
191 |
171 |
$437.17 |
| D0230 |
Intraoral - periapical each additional radiographic image |
164 |
143 |
$303.05 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$91.00 |
| D1330 |
|
17 |
17 |
$33.00 |
| D1310 |
|
18 |
18 |
$0.00 |