| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
531 |
531 |
$35K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
377 |
204 |
$25K |
| D0210 |
Intraoral - complete series of radiographic images |
380 |
380 |
$18K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
262 |
131 |
$14K |
| D4341 |
|
138 |
51 |
$9K |
| D0350 |
|
714 |
235 |
$7K |
| D1110 |
Prophylaxis - adult |
60 |
60 |
$5K |
| D1208 |
Topical application of fluoride, excluding varnish |
298 |
297 |
$5K |
| D1120 |
Prophylaxis - child |
80 |
79 |
$4K |
| D1351 |
Sealant - per tooth |
46 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
384 |
86 |
$2K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
15 |
14 |
$1K |
| D0274 |
Bitewings - four radiographic images |
13 |
13 |
$280.80 |