| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
594 |
594 |
$39K |
| D1120 |
Prophylaxis - child |
430 |
425 |
$22K |
| D0210 |
Intraoral - complete series of radiographic images |
465 |
465 |
$22K |
| D0120 |
Periodic oral evaluation - established patient |
248 |
248 |
$18K |
| D1320 |
|
481 |
481 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
451 |
449 |
$7K |
| D0274 |
Bitewings - four radiographic images |
233 |
233 |
$5K |
| D1110 |
Prophylaxis - adult |
41 |
41 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
687 |
371 |
$3K |
| D1351 |
Sealant - per tooth |
59 |
13 |
$2K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
21 |
13 |
$1K |
| D9430 |
|
41 |
39 |
$1K |
| D0350 |
|
155 |
41 |
$969.60 |
| D0220 |
Intraoral - periapical first radiographic image |
27 |
24 |
$324.00 |