| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D0150 |
Comprehensive oral evaluation - new or established patient |
1,412 |
954 |
$46K |
| D1110 |
Prophylaxis - adult |
1,394 |
947 |
$44K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
611 |
282 |
$39K |
| D0210 |
Intraoral - complete series of radiographic images |
1,062 |
626 |
$32K |
| D0330 |
Panoramic radiographic image |
782 |
586 |
$25K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
342 |
192 |
$17K |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
117 |
71 |
$8K |
| D0120 |
Periodic oral evaluation - established patient |
339 |
279 |
$7K |
| D1208 |
Topical application of fluoride, excluding varnish |
280 |
257 |
$5K |
| D0272 |
Bitewings - two radiographic images |
382 |
326 |
$4K |
| D1351 |
Sealant - per tooth |
151 |
41 |
$3K |
| D1120 |
Prophylaxis - child |
130 |
112 |
$3K |
| D0274 |
Bitewings - four radiographic images |
122 |
95 |
$510.90 |
| D0220 |
Intraoral - periapical first radiographic image |
81 |
59 |
$348.45 |