| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
646 |
595 |
$28K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
285 |
153 |
$26K |
| D1110 |
Prophylaxis - adult |
460 |
433 |
$26K |
| D0274 |
Bitewings - four radiographic images |
517 |
487 |
$18K |
| D0330 |
Panoramic radiographic image |
228 |
220 |
$13K |
| D0220 |
Intraoral - periapical first radiographic image |
692 |
622 |
$10K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
133 |
78 |
$9K |
| D0230 |
Intraoral - periapical each additional radiographic image |
781 |
567 |
$9K |
| D0120 |
Periodic oral evaluation - established patient |
223 |
209 |
$6K |
| D1351 |
Sealant - per tooth |
121 |
15 |
$4K |
| D0140 |
Limited oral evaluation - problem focused |
82 |
81 |
$3K |
| D1206 |
Topical application of fluoride varnish |
130 |
127 |
$3K |
| D1120 |
Prophylaxis - child |
78 |
75 |
$3K |
| D0210 |
Intraoral - complete series of radiographic images |
31 |
27 |
$1K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
19 |
17 |
$256.89 |