| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
275 |
275 |
$12K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
183 |
108 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
268 |
268 |
$7K |
| D1120 |
Prophylaxis - child |
410 |
410 |
$7K |
| D1206 |
Topical application of fluoride varnish |
487 |
487 |
$5K |
| D0272 |
Bitewings - two radiographic images |
236 |
236 |
$3K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
68 |
43 |
$3K |
| D0330 |
Panoramic radiographic image |
79 |
79 |
$2K |
| D1110 |
Prophylaxis - adult |
64 |
64 |
$2K |
| D0274 |
Bitewings - four radiographic images |
69 |
69 |
$1K |
| D1351 |
Sealant - per tooth |
43 |
14 |
$946.00 |
| D0210 |
Intraoral - complete series of radiographic images |
30 |
30 |
$711.00 |
| D0220 |
Intraoral - periapical first radiographic image |
67 |
64 |
$485.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
34 |
34 |
$442.00 |
| D0140 |
Limited oral evaluation - problem focused |
13 |
13 |
$314.50 |