| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,249 |
1,249 |
$83K |
| D1110 |
Prophylaxis - adult |
873 |
873 |
$78K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
1,255 |
370 |
$68K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
829 |
363 |
$55K |
| D0210 |
Intraoral - complete series of radiographic images |
1,056 |
1,056 |
$50K |
| D0120 |
Periodic oral evaluation - established patient |
576 |
576 |
$36K |
| D1120 |
Prophylaxis - child |
866 |
866 |
$33K |
| D1206 |
Topical application of fluoride varnish |
1,845 |
1,841 |
$28K |
| D4910 |
|
308 |
308 |
$24K |
| D0230 |
Intraoral - periapical each additional radiographic image |
3,800 |
1,210 |
$16K |
| D4341 |
|
196 |
54 |
$14K |
| D0350 |
|
1,272 |
442 |
$13K |
| D0274 |
Bitewings - four radiographic images |
371 |
371 |
$8K |
| D0220 |
Intraoral - periapical first radiographic image |
636 |
602 |
$8K |
| D1351 |
Sealant - per tooth |
129 |
28 |
$3K |
| D0272 |
Bitewings - two radiographic images |
141 |
141 |
$2K |
| D1310 |
|
28 |
28 |
$1K |
| D9993 |
|
16 |
16 |
$975.00 |