| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
256 |
243 |
$8K |
| D1120 |
Prophylaxis - child |
210 |
203 |
$7K |
| D1351 |
Sealant - per tooth |
269 |
30 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
569 |
279 |
$5K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
63 |
29 |
$4K |
| D1208 |
Topical application of fluoride, excluding varnish |
316 |
304 |
$4K |
| D0145 |
Oral evaluation for a patient under three years of age |
25 |
25 |
$3K |
| D0220 |
Intraoral - periapical first radiographic image |
307 |
294 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
74 |
72 |
$2K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
33 |
13 |
$2K |
| D0272 |
Bitewings - two radiographic images |
37 |
36 |
$702.66 |
| D0274 |
Bitewings - four radiographic images |
29 |
28 |
$699.06 |
| D1110 |
Prophylaxis - adult |
15 |
15 |
$603.68 |
| D0603 |
|
423 |
412 |
$0.00 |