| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
206 |
184 |
$7K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
105 |
25 |
$6K |
| D1120 |
Prophylaxis - child |
230 |
206 |
$5K |
| D1206 |
Topical application of fluoride varnish |
125 |
104 |
$2K |
| D1351 |
Sealant - per tooth |
47 |
14 |
$1K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
29 |
12 |
$1K |
| D0330 |
Panoramic radiographic image |
21 |
13 |
$546.11 |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$464.28 |
| D0272 |
Bitewings - two radiographic images |
13 |
13 |
$224.40 |
| D0220 |
Intraoral - periapical first radiographic image |
21 |
12 |
$133.40 |
| D0120 |
Periodic oral evaluation - established patient |
41 |
40 |
$0.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
42 |
41 |
$0.00 |