| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
222 |
222 |
$15K |
| D0210 |
Intraoral - complete series of radiographic images |
151 |
151 |
$7K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
56 |
14 |
$3K |
| D1351 |
Sealant - per tooth |
71 |
13 |
$3K |
| D1120 |
Prophylaxis - child |
44 |
44 |
$2K |
| D1310 |
|
28 |
28 |
$1K |
| D9430 |
|
28 |
22 |
$836.00 |
| D1206 |
Topical application of fluoride varnish |
29 |
29 |
$475.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
85 |
46 |
$336.15 |
| D1208 |
Topical application of fluoride, excluding varnish |
15 |
15 |
$280.00 |