| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
833 |
833 |
$55K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
693 |
328 |
$46K |
| D0120 |
Periodic oral evaluation - established patient |
576 |
576 |
$46K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
741 |
341 |
$40K |
| D1110 |
Prophylaxis - adult |
347 |
347 |
$31K |
| D1120 |
Prophylaxis - child |
620 |
620 |
$30K |
| D0210 |
Intraoral - complete series of radiographic images |
538 |
538 |
$26K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,574 |
909 |
$19K |
| D1208 |
Topical application of fluoride, excluding varnish |
1,204 |
1,204 |
$17K |
| D0350 |
|
1,480 |
597 |
$14K |
| D0274 |
Bitewings - four radiographic images |
525 |
525 |
$11K |
| D1351 |
Sealant - per tooth |
102 |
24 |
$4K |