| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
314 |
305 |
$21K |
| D1110 |
Prophylaxis - adult |
721 |
711 |
$11K |
| D0120 |
Periodic oral evaluation - established patient |
69 |
68 |
$6K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
71 |
45 |
$3K |
| D0140 |
Limited oral evaluation - problem focused |
48 |
48 |
$437.60 |
| D0210 |
Intraoral - complete series of radiographic images |
112 |
110 |
$418.18 |
| D0230 |
Intraoral - periapical each additional radiographic image |
225 |
222 |
$51.00 |
| D0274 |
Bitewings - four radiographic images |
160 |
157 |
$48.11 |
| D0220 |
Intraoral - periapical first radiographic image |
496 |
483 |
$10.00 |
| D1208 |
Topical application of fluoride, excluding varnish |
258 |
255 |
$0.00 |
| D1351 |
Sealant - per tooth |
150 |
34 |
$0.00 |