| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
216 |
216 |
$13K |
| D0120 |
Periodic oral evaluation - established patient |
190 |
187 |
$12K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
158 |
83 |
$7K |
| D1330 |
|
378 |
375 |
$4K |
| D1351 |
Sealant - per tooth |
146 |
42 |
$3K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
64 |
48 |
$2K |
| D1110 |
Prophylaxis - adult |
308 |
307 |
$2K |
| D1120 |
Prophylaxis - child |
54 |
52 |
$786.27 |
| D0272 |
Bitewings - two radiographic images |
336 |
333 |
$645.05 |
| D1208 |
Topical application of fluoride, excluding varnish |
226 |
223 |
$634.19 |
| D9986 |
|
19 |
19 |
$76.00 |
| D0210 |
Intraoral - complete series of radiographic images |
32 |
32 |
$0.00 |
| D0330 |
Panoramic radiographic image |
153 |
153 |
$0.00 |