| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
192 |
192 |
$13K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
86 |
38 |
$6K |
| D1110 |
Prophylaxis - adult |
56 |
56 |
$5K |
| D1120 |
Prophylaxis - child |
115 |
115 |
$5K |
| D0210 |
Intraoral - complete series of radiographic images |
70 |
70 |
$3K |
| D1208 |
Topical application of fluoride, excluding varnish |
180 |
180 |
$3K |
| D1351 |
Sealant - per tooth |
54 |
14 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
382 |
84 |
$2K |
| D0272 |
Bitewings - two radiographic images |
36 |
36 |
$432.00 |
| D0220 |
Intraoral - periapical first radiographic image |
19 |
19 |
$228.00 |
| D1320 |
|
12 |
12 |
$202.50 |
| D1310 |
|
30 |
30 |
$0.00 |
| D0603 |
|
17 |
17 |
$0.00 |