| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
387 |
370 |
$31K |
| D1206 |
Topical application of fluoride varnish |
585 |
557 |
$27K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
111 |
103 |
$22K |
| D1120 |
Prophylaxis - child |
377 |
356 |
$22K |
| D0274 |
Bitewings - four radiographic images |
343 |
330 |
$20K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
122 |
99 |
$18K |
| D1110 |
Prophylaxis - adult |
207 |
205 |
$17K |
| D1351 |
Sealant - per tooth |
85 |
19 |
$4K |
| D0272 |
Bitewings - two radiographic images |
100 |
96 |
$4K |
| D0230 |
Intraoral - periapical each additional radiographic image |
54 |
40 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
90 |
90 |
$2K |
| D0140 |
Limited oral evaluation - problem focused |
12 |
12 |
$904.00 |